“The proposed Medicare Shared Savings ACO rules make the prospect of achieving any payments so low that the investment required to participate cannot be justified.”


hospitals, or suppliers may participate in the program by creating or joining an ACO.


On March 31, the U.S. Department of Health and Human Services (HHS) and CMS issued proposed rules for imple- menting ACOs under the MSSP. A copy of the proposed rules can be found at www.cms.gov/sharedsavingsprogram. “The Affordable Care Act is putting


hart, MD, chair of Texas Medical Asso- ciation’s Ad Hoc Committee on Account- able Care Organizations.


This spring, the U. S. Centers for


Medicare & Medicaid Services (CMS), Department of Justice (DOJ), Federal Trade Commission (FTC), and Internal Revenue Service (IRS) proposed rules to govern ACOs under the Medicare Shared Savings Program (MSSP). The rules also would give physicians, hospitals, and other providers participating in ACOs some protection from antitrust charges, and provide some guidance for tax- exempt organizations involved in these entities.


In comments submitted June 5 to


Spencer Berthelsen, MD


CMS Administrator Donald Berwick, MD, Dr. Lockhart said the proposed rules “fail to further CMS’ ‘triple aim’ of better health, better care, and lower cost, and lack critical physi- cian governance provisions neces- sary to ensure the primacy of quality over lower costs.” He said the rules also are “too pre-


58 TEXAS MEDICINE August 2011


scriptive and cumbersome to permit ad- equate participation by solo physicians and small group practices.” Some large physician groups and hos- pital systems in Texas say the proposed rules are so burdensome that they will opt out of the program. “The proposed Medical Shared Sav-


ings ACO rules make the prospect of achieving any payments so low that the investment required to participate can- not be justified,” said Spencer Berthelsen, MD, chair of the Board of Managers of the Kelsey-Seybold Medical Group, a large multispecialty group in Houston. “Consequently, Kelsey-Seybold will not be able to participate.”


Sharing gain or pain? The health system reform law Congress passed last year requires CMS to estab- lish a shared savings program to improve care and lower costs. It would promote accountability for the care of Medicare beneficiaries, require coordinated care for all services under Medicare fee for service, and encourage investment in infrastructure and redesigned care pro- cesses, such as implementing electronic medical records.


Eligible health care professionals,


patients and their doctors in control of their health care,” HHS Secretary Kath- leen Sebelius said at the time. “For too long, it has been too difficult for health care providers to work together to co- ordinate and improve the care their pa- tients receive. That has real consequenc- es: Patients have gaps in their care, re- ceive duplicative care, or are at increased risk of suffering from medical mistakes. Accountable care organizations will im- prove coordination and communication among doctors and hospitals, improve the quality of care their patients receive, and help lower costs.” Under the proposed rules, ACOs that meet certain quality standards and re- duce costs by ensuring that Medicare patients get the right care at the right time — for example by improving access to primary care so patients avoid a trip to the emergency room — would share in any savings.


The quality standards fall into these five key areas:


• Patient satisfaction; • Care coordination; • Patient safety; • Preventive health; and • Care for chronic illnesses such as dia- betes, hypertension, and osteoporosis.


“An ACO will be rewarded for pro- viding better care and investing in the health and lives of patients,” said Dr. Berwick. “ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.” Also this spring, DOJ and FTC issued


a proposed antitrust enforcement poli- cy regarding ACOs participating in the MSSP. IRS issued proposed guidance on tax-exempt organizations’ participation in ACOs.


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