When CMS recently asked for input from outside entities regarding creation of potential regulations for accountable care organizations, or ACOs, and the Medicare shared savings program, the AAFP was quick to respond.
In a Dec. 3 letter to CMS Administrator Donald Berwick, M.D., AAFP Board Chair Lori Heim, M.D., of Vass, N.C., addressed a series of questions the agency posed on such topics as how to
- ensure participation by solo and small physician practices,
- create payment models and financing mechanisms that will provide access to funding capital for small practices,
- assess beneficiary and caregiver experiences as part of CMS' assessment of ACO performance,
- choose appropriate aspects of patient-centeredness to consider and evaluate, and
- decide what quality measures should be used to determine performance in the shared savings program.
Heim pointed out that the AAFP recently crafted its "Joint Principles for Accountable Care Organizations" in concert with the American College of Physicians, the American Academy of Pediatrics and the American Osteopathic Association.
In response to Berwick's question on ensuring participation by solo and small physicians, Heim noted that CMS should require ACOs to provide primary care access that is distributed evenly throughout the communities they serve and avoid exclusive contracts with single providers of primary care services "unless they can demonstrate local patient access for the entire community served." ACOs should include small practices and should provide resources to support small practices even when doing so requires an "upfront" investment by the ACO, said Heim.
In addition, she noted, CMS "should not accept conceptual models where the ACO is run by a hospital that sets up primary care solely to serve as a feeder route for expensive procedures or hospital services." She pointed out that small practices will have difficulty participating in ACOs that only serve Medicare patients. "The percentage of patients in a single practice will be too small to warrant the logistical changes required to participate," said Heim.
The Academy also urged CMS to remove barriers to clinical and financial integration that currently exist. Doing so will allow independent practices to participate in ACO models. "This may require changes to -- or waivers from -- current antitrust law and regulations governing such business relationships," said Heim.
In terms of providing small practices access to capital, Heim told Berwick that many small practices have limited access to capital or other resources from which they could generate shared savings for the ACO. Ideally, said Heim, primary care practices should receive per-patient, per-month care management payments, and these payments should not be made from any shared savings calculation because they support ongoing fixed costs not related to individual visits.
Upfront or monthly payments to primary care practices should be recognized as "necessary and ongoing support for nonvisit-based services, such as patient self-management support, care management and care coordination," said Heim, adding a prepaid monthly care management fee also would help demonstrate the importance of the team approach to health care.
Heim also addressed assessing beneficiary and caregiver experiences in an ACO. "ACOs should be required to survey patients so that service levels can be determined and improved," said Heim. She added that ACOs should have systems in place to collect and act on patients' "experience of care" data and show positive trends over time.
Patients want to know that their primary care physicians and team members are listening to patient health concerns and symptoms, Heim said. Patients also want to know that their health outcomes are improving because of the care they receive.
Heim noted that patients will need assurances they are receiving better health care and evidence-based health care. For example, said Heim, outcome measures for common chronic illnesses already exist. She urged CMS to develop additional measures for continuity of care and comprehensiveness of care. And she asked CMS to invest in the implementation of measures to monitor a patient's functional status and quality of life.
In response to Berwick's request for suggestions on alternative payment models, Heim ticked off several models that should be tested:
- global payments for comprehensive primary care services,
- partial capitation for specialty and hospital care, and
- blended payment systems that combine fee-for-service, care management payments and incentives for achieving quality benchmarks.
Finally, Heim urged Berwick to expand care management and care coordination services beyond certain patient groups, such as patients with congestive heart failure. "We believe that all patients will benefit from these same services," said Heim.