Donald W. Fisher, PhD, president of the American Medical Group Association, outlines five concerns his members, limited to large physician groups, have with the proposed regulations for accountable care organizations, as outlined in a recent letter to CMS Administrator Don Berwick, MD.
1. Risk-sharing requirement. Under the proposal's "one-sided risk" model, an ACO would pay no penalty if it spent more in the first and second year, but the penalty would start in the third year. "This isn’t enough time to do the downside risk," Dr. Fisher says. He proposes keeping the one-sided risk model longer.
2. Baseline for patient severity. If the ACO starts with fairly healthy patients and then attracts sicker patients, the initial level of severity applies to all three years. Dr. Fisher says the baseline should be measured each year, because patients with higher severity could be attracted to the program as it goes forward.
3. Retrospective attribution. "CMS is not going to tell ACOs which patients are covered until a year after the fact," Dr Fisher says. "It's really hard to drive up quality and lower costs for patients when you don't know who they are." Patients should be identified when they are attributed.
4. Quality measurement requirements: An ACO would have to report 65 measures of quality in the first year. Then in years two and three their quality data will be scored and affect the ACO's shared savings payment. "Reporting 65 different measures from Day One is an awfully large number," Dr. Fisher says. He proposes that the measures be phased in over the three years, starting with high-volume diseases and conditions.
5. Minimum savings requirement: Under the proposal, the savings threshold has to reach 3.9 percent for a low population of 5,000 beneficiaries and will lower to 2 percent for a population of 60,000 beneficiaries, which is a very large group. Instead, Dr. Fisher wants to start with a threshold of 2 percent for smaller ACOs and reduce that down to a fraction of 1 percent for a large population.
"If this proposal isn't changed, we will have missed a huge opportunity to reform the delivery system," Mr. Fisher says. The section on ACOs and shared savings is "one of the only pieces of the law that deals with true healthcare reform," he adds. "The rest basically deals with insurance reform." The law also creates the Center of Medicare and Medicaid Innovation, which is charged with coming up with more innovations, but it will take a while for the center to make proposals, he says.
In addition, AMA President Cecil Wilson, MD, has stated that it would be difficult for practices to afford the cost of setting up an ACO. But that problem only applies to small practices and not the large medical groups that are members of AMGA, Dr. Fisher says. He says they have the infrastructure to start ACOs.
Learn more about the American Medical Group Association.
Read the letter to Dr. Berwick on the proposed ACO regulations.
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