Sour note on ACOs

AMGA en­dorsed con­cept, but hates pro­posed regs

Modern Healthcare - - The Week In Healthcare - Andis Robeznieks

The as­so­ci­a­tion that says it wrote the tune to ac­count­able care doesn’t like how the CMS is cov­er­ing its song. Al­though its for­mal re­sponse to the pro­posed CMS reg­u­la­tions for ac­count­able care or­ga­ni­za­tions is still be­ing de­vel­oped, the Amer­i­can Med­i­cal Group As­so­ci­a­tion took the ex­tra step last week of writ­ing a letter to Dr. Don­ald Ber­wick to let the CMS ad­min­is­tra­tor know how dis­pleased the or­ga­ni­za­tion’s mem­ber groups are with the gov­ern­ment’s rough draft of the ACO rules.

The CMS also drew a neg­a­tive re­view from the 10 physi­cian groups that par­tic­i­pated in Medi­care’s demon­stra­tion pro­ject test­ing in­cen­tive pay­ments sim­i­lar to the ones un­der­pin­ning the gov­ern­ment’s ACO ex­per­i­ment.

In­stead of just singing the “Look What They’ve Done to My Song, Ma” blues, the AMGA may leave the agency stand­ing on stage by it­self.

AMGA Pres­i­dent and CEO Don­ald Fisher told Mod­ern Health­care the or­ga­ni­za­tion may turn its fo­cus to the pri­vate sec­tor if the CMS doesn’t ad­dress its con­cerns and is talk­ing with Amer­ica’s Health In­surance Plans, the trade group rep­re­sent­ing the nation’s largest in­sur­ers, to de­velop a com­mer­cial-payer ACO model.

The AMGA of­ten takes credit for get­ting the ACO con­cept into the Pa­tient Pro­tec­tion and Affordable Care Act. Its mem­ber­ship con­sists of 390 large, mul­tispe­cialty med­i­cal groups in which 117,000 doc­tors prac­tice, and these groups are con­sid­ered by many to be the prime can­di­dates for form­ing the nation’s first Medi­care ACOs.

But in the letter to Ber­wick, Fisher said a sur­vey of its mem­bers found that 93% would not en­roll as an ACO un­der the cur­rent reg­u­la­tory frame­work.

“Our mem­ber­ship’s con­cerns were many and fo­cused on is­sues such as the risk-shar­ing re­quire­ment, static risk ad­just­ment, ret­ro­spec­tive at­tri­bu­tion, qual­ity mea­sure­ment re­quire­ments, the min­i­mum sav­ings re­quire­ments and oth­ers,” Fisher wrote. “With­out sub­stan­tial changes in the fi­nal rule, we fear that very few providers will en­roll as ACOs and that CMS and the provider com­mu­nity will miss the best op­por­tu­nity to in­ject value and accountability into the de­liv­ery sys­tem.”

De­spite its dis­plea­sure with the CMS frame­work—which is de­scribed in the letter as “overly pre­scrip­tive, op­er­a­tionally bur­den­some”—the AMGA is not about to aban­don the ACO con­cept. “We’re look­ing to con­tinue to move for­ward, but to fo­cus much more on the com­mer­cial side and work more with AHIP now than on the fed­eral gov­ern­ment side,” Fisher said in an in­ter­view.

AHIP spokesman Robert Zirkel­bach said ev­ery­thing is still in the pre­lim­i­nary stages, but that his or­ga­ni­za­tion’s par­tic­i­pa­tion would have two com­po­nents: cre­at­ing part­ner­ships and strength­en­ing ad­vo­cacy ef­forts. “We can fa­cil­i­tate health plans part­ner­ing with providers who are look­ing to de­velop ACOs,” he said. “The AMGA can iden­tify providers who are ready and we can iden­tify the health plans.”

He added that if health plans and providers spoke to­gether, it’s more likely the CMS will hear them. “If we work to­gether to iden­tify com­mon themes, we can share them in our com­ments to reg­u­la­tors and have a com­mon front on key is­sues,” Zirkel­bach said.

In his letter to the CMS, Fisher said that if ACOs are not suc­cess­ful, “dra­co­nian cuts across the provider spec­trum” may emerge as the only al­ter­na­tive to de­liv­ery-sys­tem re­form.

The 10 par­tic­i­pants of the CMS’ five-year Physi­cian Group Prac­tice Demon­stra­tion sent a sim­i­larly neg­a­tive letter to Ber­wick, warn­ing that with­out changes, none would par­tic­i­pate.

The sig­na­to­ries—which in­clude Geisinger Clinic, Danville, Pa.; Marsh­field (Wis.) Clinic; and Dart­mouth-Hitch­cock Health, Lebanon, N.H.— said they “all have se­ri­ous reser­va­tions about the eco­nom­ics and the com­plex­ity” of the pro­posed frame­work for Medi­care ac­count­able care.

The letter cites the down­side risk dur­ing the ini­tial three-year term, com­pounded by sig­nif­i­cant in­vest­ment cost. Physi­cians and hos­pi­tals would be el­i­gi­ble for bonuses or penal­ties based on qual­ity per­for­mance and cost con­trol. On av­er­age, ac­cord­ing to the letter, it costs $30,000 to pro­gram a sin­gle qual­ity met­ric. That means the 60 met­rics pro­posed by the CMS would equate to an in­vest­ment of about $2 mil­lion.

For­mal com­ments on the pro­posed rules are due June 6.

—with Me­lanie Evans

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