The accountable care dilemma
Some of my colleagues have asked me whether accountable care organizations (ACOs) have a realistic chance of meeting expectations as proposed in the recently-announced regulations from CMS. My answer is that they do not. In attempting to craft a politically acceptable program, CMS has failed to address key issues on the one hand, or over-regulated by providing prescriptive parameters for ACO operations that do not allow for local innovation on the other.
Here’s an area where CMS dropped the ball, failing to address a key problem. Medicare beneficiaries will be retrospectively assigned to ACOs by "attribution logic." In the regulations, that means patients will be assigned at the end of a period if the majority of care is provided by a physician in an ACO. At this time the patient has the chance to continue with the physician member or choose another physician.
Even if the Medicare enrollee chooses to remain within the ACO, they can still receive care anywhere – in or out of the ACO network. If the Medicare patient is unwilling to follow the ACO care plan, receives care elsewhere and then returns to the ACO system, the ACO can be penalized for a lack of quality of care. In other words, ACO providers could be held “accountable” for someone else’s mistakes.
On the other side of the argument, some of CMS’ proposed policies are too restrictive. For instance, CMS requires each ACO to submit for approval any written materials, calls, ads, web pages or community events that will be used to contact beneficiaries or providers/suppliers about the ACO. There are even specific requirements for whom and how many different types of leaders need to be included in the ACO governing body.
By regulating every little action that must be performed by the ACO, while leaving major issues about patient responsibility off the table, CMS has crafted an almost perfectly undesirable outcome. And then they take things a step further, requiring 50% of the ACO’s physicians to be certified meaningful users of electronic health records, and payment models that require risk and only provide back 50% to 60% of the shared savings.
Make no mistake, I support accountable care. In fact, I believe that it is the best way to change this system to finally provide healthcare as opposed to sick care, and to cure our national addiction to fee-for-service payments. But if CMS doesn’t make major changes to this rule, they risk hosting a party that no one bothers to attend. And while there are other markets and payor partners willing to pursue accountable care the right way, it would be a tremendous loss if the largest payor in the nation – and the one funded by taxpayer dollars – was left out of the innovation.
Mike Stephens blogs regularly at Action for Better Healthcare.
