Summary Report: CMS Session on Accountable Care Organizations | August 12, 2010
This meeting was conducted by officials in CMS' Office of External Affairs to help further the agency's conversation on the topic in advance of its promulgation of a proposed rule/implementation of the program. In particular, the agenda included a discussion on an array of topics, such as those that pertain to beneficiary issues (e.g., Medicare beneficiary assignment, engagement, etc.); care transformation (e.g., improving beneficiaries' health outcomes); and ACO business case considerations (e.g., factors that an organization might consider when deciding whether to participate under such a program).
Participants included, among others, representatives from large physician group practices involved in the Medicare Physician Group Practice Demonstration, the American Medical Association, the American Hospital Association, the National Partnership for Women and Families, the Center for Medicare Advocacy, the American Osteopathic Association, the New Hampshire Institute for Health Policy and Practice, the National Committee for Quality Assurance, and the California Association of Physician Groups.
At the outset of the session, the event moderator/facilitator, CMS Office of External Affairs official Susie Butler, indicated that the agency is still in the "early stages of development" of the program and is actively seeking stakeholder input on a number of issues relative to the agency's forthcoming implementation of the program. On this note, the public is encouraged to offer comments on the evolving ACO model, Ms. Butler said, via its centralized mailbox: aco@cms.hhs.gov. Later during the meeting, CMS' Dr. Terri Postma of the Center for Medicare's Performance-Based Payment Policy staff clarified that the agency intends to issue a notice of proposed rule-making (NPRM) on the ACO program by year end. Following the promulgation of such rules, the public will have the opportunity to provide comments over a 60-day specified period, Dr. Postma continued. Dr. Postma noted that the agency hopes to hold more listening sessions on the matter in the near future.
Although there were a handful of CMS officials present at the meeting, as well as some who joined by phone, the bulk of the two-hour session was spent having invited participants respond to a number of questions posed by the moderator/facilitator, Ms. Butler. Aside from Dr. Postma's brief remarks on process, as noted above, there was no formal or prepared presentation by CMS staff, nor did the event serve as an opportunity for CMS staff to answer any questions raised by the session participants, since doing so might in some way compromise the construct of the rule-making process.
With respect to the first broad topic of discussion - "beneficiary issues" - Ms. Butler asked for feedback from the session participants on how the agency might best align beneficiaries with a participating ACO. Generally speaking, participants favored the notion of having beneficiaries be informed of their participation in an ACO, as well as ensuring that providers are notified of whom they are responsible for treating (i.e., patient assignment). Paul Cotton with the National Committee for Quality Assurance advocated for what he termed a "soft lock" such that beneficiaries would be assigned to providers under an ACO but would have the option to leave if desired. Regarding beneficiary engagement within an ACO model, some participants suggest that there be some way to incent or engage patients to be a part of an ACO. To this, Don Crane with the California Association of Physician Groups suggested that there ought to be differing co-payments such that beneficiaries would pay more outside of an ACO than they otherwise would through their participation in an ACO.
On issues concerning the agency's assessment of the program's impact on beneficiaries, several participants took the opportunity to stress the need to have strong performance metrics (including those that are comparative in nature). For instance, there could be metrics that allow one ACO to compare itself to another, or to compare itself against the Medicare fee-for-service population. Metrics that speak to cost, quality and patient safety also would be needed.
On the second broad issue of "care transformation," CMS asked participants to consider the elements of care that ought to be addressed as a priority under ACOs. Participants discussed the need to focus on care coordination - and incenting such practice - in addition to ensuring that the burden on coordinated care not fall exclusively to primary care physicians. On the latter note, there was also some discussion at the outset of the meeting regarding the definition of "primary care services" in terms of whether other provider types would be included so as to help foster a more cohesive and coordinated model. A number of participants, including the AHA's Beth Feldpush, urged CMS to "tread carefully" in its development of the forthcoming rule so as to not only regulate but also provide a certain degree of flexibility to ACOs (e.g., to be able to define, as it relates to each ACO, what "patient-centered" care truly means).
CMS staff also asked for feedback on ways in which the agency can be a more effective partner in helping ACOs transform care, to which a number of individuals, including Dr. Nick Wolter of the Billings Clinic, spoke to the importance of having timely data. Dr. Wolter stressed the need for ACOs to know not only who their patients are but also more about the demographics of the patient population served so as to enable providers to make more informed decisions and better coordinate care. Dr. Wolter and others also spoke to some of the challenges under the existing PGP Demonstration - a demonstration considered to be a forerunner to the ACO model - including issues related to risk adjustment, timeliness of the data, and thresholds (e.g., around proposed confidence intervals).
With respect to the type of data that might be highly sought or needed by a participating ACO under such a program, several participants offered comments to CMS on this front, including Don Crane with the California Association of Physician Groups, who recommended that ACOs have access to timely claims, laboratory and pharmacy data. Heather Staples with the New Hampshire Institute for Health Policy and Practice indicated that under her organization's current model, they are receiving claims data on a quarterly basis and have found such data to be effective in terms of influencing the overall decision process, but perhaps not timely enough for making decisions at a patient's point of care (e.g., when in the hospital).
On the last broad topic of "business cases," participants discussed a number of factors that play a role in shaping an organization's decision to pursue an ACO, including those focused on both clinical and financial reasons. With respect to the latter, some participants discussed the need for early guidance from CMS on key issues of concern regarding shared savings model organizational structure and operation, including those related to Stark law.
