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CMS draws mixed reviews with the release of proposed ACO rules
Beware of bias in quality measures, critics say
The release by the Centers for Medicare & Medicaid Services (CMS) of a proposed rule to govern the operation of Accountable Care Organizations (ACOs), a new form of organization that may consist of physicians, hospitals, other health care providers and suppliers, has drawn a mixture of praise and criticism from quality experts interviewed by HBQI. The rule, as is typical with CMS proposals, has been made available for public comment, and observers anticipate the final rules will be issued in the fall. The start date for the new program is Jan. 1, 2012.
The proposal outlines quality standards that ACOs must meet in order to benefit from financial incentives (The Medicare Shared Savings Program) being offered by CMS. They fall into five key areas:
ACOs could also be vulnerable financially if they fail to meet these standards. "An ACO will be rewarded for providing better care and investing in the health and lives of patients," said Donald M. Berwick, MD, CMS Administrator, in a statement released by CMS. "ACOs are not just a new way to pay for care but a new model for the organization and delivery of care."
"I think an ACO absolutely makes sense because it centers around populations of patients," says Joan Phillips, MSN, RN, ACNS-BC, administrative director and chief nurse executive, who oversees Integrated Medical Services for Beaumont Hospitals in Royal Oak, MI. "It's a great idea, but it will be challenging to meet some of the requirements."
The concept of an ACO "absolutely assists in coordinating patient care," she continues. "As a nurse I can tell you we try to be a 'nurse navigator' and help patients through the system, but that's hard even for us and we know the system. One of its good points is that it helps create that continuum of care for patients to help link care from pre-hospital to hospital to outpatient to rehab. It will be a huge task, but once we do that our patients will get better care."
The program, she continues, also provides a focus on the patient in a more consistent manner. "Now, it's fragmented," she observes. "Every provider is concerned about their little domain; this helps connect those dots with the patient at the center. I hope it will decrease unnecessary testing and overall medical costs."
"It's a mixed bag," adds Amanda Forster, a spokesperson for Charlotte, NC-based Premier, Inc. "CMS got some things really right. For example, there's a real willingness to share timely data; upon request they will make performance data available on a monthly basis, and that's critical. They've also allowed for multiple payment models, so you can test a few different approaches. That's critical, too, because hospitals and health systems are definitely at different points in their journeys."
Forster says CMS got a lot of legal issues right, as well. "They cleared up things a lot around clinical integration, granting safe harbor, and antitrust concerns," she observes. "All those things were greatly helpful, and clear away a lot of barriers that had stood in the way of integration and overcoming fragmentation." She adds, however, "Some tweaking needs to be done for them to be more effective." (The proposed rule and joint CMS/OIG notice are posted at: www.ofr.gov/inspection.aspx.)
Why just Medicare?
One of Forster's criticisms of the program is that the approach may be too limited. "Pursuing accountable care is a smart move a good move but there are a lot of options on how to engage and with whom; Medicare is not the only market with which to pursue an ACO," she says. "There are lots of populations and potential payer partners we should be thinking about. You can start with your own system's employees, provider-sponsored plans, commercial insurers, unions, all of whom can work out different agreements. We've been working with our own accountable care collaboratives; members of our implementation group were working on accountability in the private market before any rule was out. From our experience, we've discovered a lot of different places where you can play and not necessarily be in the Medicare market."
Forster also says CMS should rethink the shared savings amount it has put forward. "We think it should be 70%-80% of the total versus 50%-60%," she says. "The reason is that, especially in the initial years, the investment required to transform your status quo model will be significant in terms of technology and process change."
Phillips also has concerns, particularly about technology. "Developing an IT infrastructure is probably the biggest challenge for most hospital systems; not only do they have to provide infrastructure in the system, but create a 'bridge' to the medical office for the physician, so there will be a smooth flow of information," she notes.
Another challenge, she continues, is that hospitals will have to create "medical homes" for patients within physician offices. "We'll have to do a lot of work to help practices create this medical home that meets all the CMS criteria," she says.
But will they work?
Paul Frisch, JD, senior compliance consultant, with Apgar & Associates in Portland, OR, has real concerns about whether hospitals and health systems should participate in ACOs. "I think it's a challenge; are they going to have the success or failure of the 10 large groups that worked in a CMS study for five years?" says Frisch, who previously served as general counsel to the Oregon Medical Association. "Six out of the 10 had problems, and only two of the 10 were actually profitable," he says. (The New England Journal of Medicine published an analysis of this demonstration project. See Reference 1 at the end of the article.)
"The question I raise is this: If these organizations that were essentially self-selected for their size, financial acumen, and for their expertise in delivering coordinated care couldn't make a go of it, what is to suggest that any group that decides to form an ACO will have any better luck or more importantly, will they do worse and be a disaster?" Frisch says.
Many organizations think they can do better, he says. "If that's true, great but I see it [the study] as a cautionary tale. Most organizations have no idea what kind of financial investment is going to be needed.
"If I were a hospital or a physician group, the first thing I'd want to do is take a very close look at the results of that study and see why we were different enough not to run across the same problems," he continues. "Also, I think a lot of tools identified as part of coordinated care, particularly EMRs, are overrated. Everything I read and people I've talked to think there is unrecovered reduction in production."
Concerns about guidelines
Frisch also has real concerns about guidelines. "The whole principle of this new type of managed care and that's really what it is, just with a different vocabulary is that since what we're looking for is excellent quality and low cost, guidelines are a holy grail," he says. "The dirty little secret is that everyone who works on them does not necessarily have to disclose conflicts of interest."
Frisch says that in a lot of the work done in clinical practice guidelines, it turns out that researchers received financial support from drug companies or medical device firms. "When people are considered experts, large companies come to them and pay them to give speeches about clinical matters that positively affect these drugs," he notes. "That's a very significant problem."
How might that impact ACOs? "It affects what guidelines to choose: Who's behind them, and who paid people to promote those guidelines? Nobody knows for sure," he says. If this were not an issue, he continues, we would not have seen the recent reports by the Institute of Medicine on developing standards for systematic reviews of clinical practice guidelines. ("Clinical Practice Guidelines We Can Trust": http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx.)
"The IOM has it right; before we get too far into reliance on clinical practice guidelines, there needs to be a thorough vetting of them to make sure no undisclosed influence or biases exist, or if there is a lack of scientific evidence in support of the guidelines," Frisch says.
A done deal?
Quite often when CMS issues proposed rules, when the period for public comment ends and the final rules are issued, observers find that not much has changed. Frisch believes that will be the case here. "I think there will be a lot of public comment and a large record of industry comment, but as a practical matter I think it is a done deal," he asserts. "The reason I'm concerned with that is we really have a deadline at the end of this year, so whatever those rules dictate, things are going to be set in stone fairly quickly. It's probably more important with IOM calling for these standards, but I don't think there's enough time; people are in a rush."
Forster disagrees. "It's probably premature to say this ACO model makes sense or not because CMS made it very clear they want feedback," she says. "If you present good reasons for why something needs to happen they are signaling that they're willing to make changes. So, whether people should make a 'yes' or 'no' decision really depends on what CMS needs to do next, and what we see in the final rule."
Forster adds that CMS "almost went out of their way to say CMS welcomes comments. The difference, say, between proposed rules for shared savings versus proposed and final OPPS [Outpatient Prospective Payment System] rules is that this is a wholly different concept for CMS to take on. They acknowledge that this is a totally new and different area for them, and that they're open to other opinions."
The other thing to bear in mind, she adds, is that while this is the "permanent program," CMS says it will be introducing some pilot programs that could also be based around accountable care principles. "So, for instance, you might want to participate in a bundle payment pilot with CMMI [The Center for Medicare and Medicaid Innovation]," Forster says. "There will be a lot of different tracks for Medicare, and then a whole spate of private and other payers."
[For more information, contact:
Amanda Forster, Senior Director, Public Relations, Premier, Inc. Phone: (202) 879-8004; E-mail: Amanda_Forster@PremierInc.com
Paul Frisch, JD, Senior Compliance Consultant, Apgar & Associates, Portland, OR. Phone: (503) 997-1099; E-mail: firstname.lastname@example.org
Joan Phillips, MSN, RN, ACNS-BC, Administrative Director and Chief Nurse Executive, Beaumont Hospitals, Royal Oak, MI. Phone: (248) 457-7625; E-mail: JPHILLIPS@beaumonthhospitals.com]