Ev­ery­one’s look­ing to gain an edge in the up­com­ing regs gov­ern­ing ACOs

Modern Healthcare - - Front Page - Melanie Evans

With pro­posed ACO reg­u­la­tions on the hori­zon stake­hold­ers an­gle for fa­vor­able pro­vi­sions

They won’t all get ev­ery­thing they want.

In a raft of re­cent com­ment letters sprin­kled with rec­om­men­da­tions and a few warn­ings, pretty much any party with a stake in health­care de­liv­ery or an opin­ion about it has now weighed in on op­tions that face the CMS as it de­vises reg­u­la­tions for Medi­care ac­count­able care or­ga­ni­za­tions.

The CMS is ex­pected to de­liver a pro­posed rule in the first weeks of 2011.

The Pa­tient Pro­tec­tion and Af­ford­able Care Act calls for Medi­care to pay bonuses to such or­ga­ni­za­tions be­gin­ning in 2012. But the law says lit­tle, be­yond a ba­sic frame­work, about how the pro­gram would op­er­ate.

The letters un­der­scored prac­ti­cal and le­gal chal­lenges al­ready widely de­bated among pol­i­cy­mak­ers and or­ga­ni­za­tions hop­ing to launch such net­works.

But the com­ments—com­ing from ma­jor in­sur­ers, health sys­tems, med­i­cal de­vice mak­ers, phar­ma­cies, re­tail clin­ics, em­ploy­ers, se­nior ad­vo­cacy groups, state agen­cies, as­so­ci­a­tions and med­i­cal groups—also high­lighted di­vid­ing lines among in­dus­try play­ers as reg­u­la­tors search for ways to over­haul pay­ment from one of the nation’s largest pay­ers.

The re­sponse un­der­scores mount­ing in­ter­est in pay­ment mod­els that might slow the rise health­care costs as more house­holds are un­able to af­ford care, em­ploy­ers are strained and the fed­eral deficit swells. But some health pol­icy ex­perts cau­tion the ac­count­able care model has yet to be proven, a warn­ing per­haps sup­ported by the letters’ calls for ex­per­i­men­ta­tion and some­times con­flict­ing pro­pos­als for how reg­u­la­tors should pro­ceed.

“I would like to see the abil­ity to eval­u­ate, to can­cel or to ad­mit we made a mis­take if it doesn’t work out,” said Mark Pauly, a health econ­o­mist and pro­fes­sor at the Uni­ver­sity of Penn­syl­va­nia Whar­ton School.

As his agency at­tempts to as­sem­ble the nuts and bolts, CMS Ad­min­is­tra­tor Don­ald Ber­wick in pub­lic re­mains fo­cused on the big­pic­ture prom­ise of ACOs and the op­por­tu­nity for each al­liance to go its own way. Much will de­pend on the re­sources, providers, his­tory and geog­ra­phy of lo­cal com­mu­ni­ties, he said dur­ing a speech last week at the Com­mon­wealth Club in San Fran­cisco.

“I think we are go­ing to see a re­birth of or­ga­ni­za­tions able to make care a jour­ney and not a frag­men­ta­tion,” Ber­wick said. “Or­ga­ni­za­tions that will have mem­o­ries about pa­tients, not am­ne­sia.”

And as he has be­fore, Ber­wick warned there will be two camps in re­sponse to the changes un­der the re­form law. One will be “au­then­tic, they will be the real part­ners on a great na­tional ex­pe­di­tion.” The oth­ers, he said, will use the new terms, such as ACOs, but “they will be­come cloaks of the sta­tus quo.”

More good than harm?

Some of the com­menters ar­gued that hos­pi­tals and doc­tors in ac­count­able care groups should be at risk to lose money as well as earn bonuses for qual­ity and sav­ings achieved, as pro­posed in the law. Yet oth­ers said they feared such a mech­a­nism could bur­den providers with fi­nan­cial risks akin to in­sur­ers,


CMS Ad­min­is­tra­tor Don­ald Ber­wick says the suc­cess of ACOs will de­pend on a vari­ery of fac­tors, in­clud­ing com­mu­nity re­sources.

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