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CMS has given you time to comment on new rules for ACOs
e-Reports, April 18, 2011
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New rules and guidelines for accountable care organizations (ACOs) were released March 31, and the federal government wants to know what you think about them. You have 60 days – until June 6 – to respond. The Centers for Medicare & Medicaid Services (CMS) will consider comments from beneficiaries, suppliers and health care providers before developing final regulations to direct ACOs, set to become operational under Medicare Jan. 1, 2012.

Fact sheets for easy reading

Fact sheet Overview 

Fact sheet for providers 

Fact sheet on legal issues 

Fact sheet summary of proposed regulations 

Fact sheet on quality scoring

Tom Neal, attorney with Krieg DeVault, said, “These proposed rules are incredibly intrusive, comprehensive in the manner of detail in which the government is attempting to direct the delivery of care to the patients who would be assigned to such an organization.”

In fact, five separate federal agencies have released documents that comprise the proposed ACO rules and guidelines for the Medicare Shared Savings Program. Here are links to help you find the new information:

  • Find the notice in the Federal Register.
  • See the CMS proposed rule on ACOs and the new shared savings program on the CMS website.
  • Read the Federal Trade Commission/Department of Justice proposed enforcement policy on antitrust law on the FTC website.
  • See an IRS notice about the need for guidance for tax-exempt organizations on the IRS website.

Why ACOs?
At a time when health care costs are continually increasing and unsustainable, the Affordable Care Act proposed ACOs as a way to persuade physicians and others in health care to work more closely and share information. If you join an ACO and save resources through more efficient service, the CMS will share the savings with you, but your participation is voluntary.

“CMS is concerned about quality and cost, which is nothing new,” said Neal. “The trouble is there seems to be a lack of awareness – perhaps a lack of exposure to the reality of the workplace and marketplace – by the authors of such rules, regarding the ability of practitioners and facilities to jump through all these very expensive and complicated hoops.”

CMS noted more than half of Medicare beneficiaries have five or more chronic conditions – like diabetes, arthritis, hypertension and kidney disease. Failure to coordinate care leads to increased suffering, medical errors and duplicative care.

One analysis suggests Medicare could save as much as $960 million over three years by improving coordination and communication. In Indiana, at least four entities have confirmed to the ISMA they are forming ACOs (see Oct. 12, 2010 issue of ISMA Reports).

“The goals here are to save the federal government money, but the costs on the other side of the table to providers to achieve the sea change in a delivery system on a national scale, to flip everyone into a risk-based, integrated model are significant,” Neal concluded. “Medicare isn’t going to pay for that. So where the money is to come from is not known; it will not come from a Shared Savings Program based on the Medicare fee schedule.”

After allowing time for consideration and review, ISMA Reports will seek further reaction to the guidelines. Watch upcoming issues and refer to the ISMA’s Web page on ACOs here.

The AMA’s response

The AMA announced it would fully review the proposed CMS rule on ACOs, as well as the FTC draft statement of policy.

“ACOs offer great promise for improving care coordination and quality while reducing cost, but only if all physicians who wish to are able to lead and participate in them. For this to happen, significant barriers must be addressed, including the large capital requirements to fund an ACO and to make required changes to an individual physician's practice, existing antitrust rules and conflicting federal policies,” said Jeremy A. Lazarus, M.D., speaker of the AMA House of Delegates.

The AMA recommended to CMS how to make it possible for physicians in all practice sizes and settings to successfully lead and participate in ACOs, including flexible requirements for ACO structure, transitional steps for ACO formation, increased access to loans and grants for small practices, easing of antitrust restrictions, and timely access to quality data.

See the AMA letter with its recommendations here.
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