by rewarding greater efficiency and qual- ity,” Dr. Lockhart said. Dr. Lockhart also complained the rules set up too many administrative and financial barriers to make ACO partici- pation feasible for solo physicians and small group practices, which make up most of the physician practices in Texas. TMA also opposed provisions that would allow CMS to assign patients to an ACO retrospectively, which he says would leave ACO participants “completely in the dark” about which Medicare patients for whose care they will be financially responsible.
In its comments, the American Medi-
cal Group Association (AMGA), which represents nearly 400 multispecialty groups and integrated health systems, said ACOs will be unsuccessful from the start without dramatic changes to the CMS rules.
CMS has “created a design specifica- tion encompassing onerously complex application and participation require- ments coupled with unbalanced risk/ reward criteria that disadvantages ACO entities,” the group said.
Flying blind While TMA expressed concern for small groups and solo physicians, some large group practices and health systems also say they are unwilling to participate in the MSSP under the proposed rules. Carl Couch, MD, president of the Baylor Quality Alliance, an ACO being formed by the Baylor Health System in
the Dallas-Fort Worth area, says his or- ganization does not intend to apply for MSSP certification. “We think that there are numerous parts of that that are unworkable,” Dr. Couch said. First among them is the ret- rospective assignment of patients. “The idea of retrospective attribution
makes no sense to us,” he said. “How do I really get involved with and help manage the care of patients to whom I’m retrospectively attributed? That is a complete conundrum to us and not something we see ourselves able to work with. My simple analogy is Medicare is asking us to fly the airplane into the air- port without instruments, and they’ll tell us later whether we crashed.” Dr. Couch says another problem is that patients are allowed to seek care outside the ACO and can elect not to have their data measured as part of the quality measurements. That, he says, means there is no accountability what- soever on the part of patients. Finally, he says CMS has included 65 separate quality standards that must be measured and reported on, which he says are “so prescriptive that we find that a little rigid.”
AMGA also complained about the
number of quality measures, calling them unreasonable. That group recom- mends that the quality measures be lim- ited to 32 and that they be phased in over three years. And, Dr. Berthelsen says the potential financial rewards for the ACOs are just
too small to provide any real incentive to participate.
“I’m a firm believer in the concept of accountable care and accountable care organizations,” Dr. Berthelsen said. “But, in general, the amount of potential dol- lars that an organization could achieve out of this are small relative to the num- ber of dollars and effort required to qual- ify for the dollars.” Dr. Berthelsen says the rules cap the amount of savings ACOs can share at 7.5 percent for ACOs that choose the shared-savings-only payment track and 10 percent for those that opt for the shared-savings-and-losses track. So, there is no financial reward for the ACO if it achieves savings above those levels, he says. The ACO’s share of the savings they achieve is 50 percent for the first pay- ment option and 60 percent under the second. AMGA suggests boosting those levels to 70 percent for the payment track with no downside risk and 80 per- cent for the two-sided payment track.
Carving out safety zones TMA also found fault with the DOJ and FTC antitrust enforcement policy. Dr. Lockhart says it fails to take into account the realities of medical practice, particu- larly in rural communities. The proposed policy allows an ACO in a rural area to include just one physi- cian per specialty from each county in the primary service area. “Under the rural exception, as cur-
ACOs explained
To help physicians make informed decisions about participating in accountable care organizations (ACOs), TMA sponsored a series of seminars in June and July. Resource materials from those seminars are still available on TMA’s website at
www.texmed.org/acoseminar/. Physicians who missed those seminars may purchase a copy of
the course syllabus for $50. To order a copy, contact Cheryl Krhov- jak at
cheryl.krhovjak@
texmed.org, or call (800) 880-1300, ext. 1452, or (512) 370-1452.
60 TEXAS MEDICINE August 2011
rently drafted, TMA is unable to discern whether a physician could take a vaca- tion or utilize other specialists for call coverage when he or she is otherwise unavailable for patient care,” Dr. Lock- hart wrote in comments to the FTC. “To deliver high-quality care, more than one physician per rural county per specialty is necessary.” CMS, FTC, and the other agencies are
reviewing comments to their proposed rules and are expected to issue final reg- ulations and policies later this year. Final rules must be in place by Jan. 1, 2012.
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