Although properly structured accountable care organizations, or ACOs, can make America's health care delivery system "more accountable and more focused on value instead of volume," the AAFP is concerned that, as currently proposed, Medicare's ACO program "will fail to offer the potential benefits of better care for individuals, better health for populations, lower per capita costs for Medicare beneficiaries and improved coordination among physicians." That was the message AAFP Board Chair Lori Heim, M.D., of Vass, N.C., recently sent to CMS Administrator Donald Berwick, M.D.
Heim's May 20 letter(8 page PDF) is in response to CMS' proposed rule(edocket.access.gpo.gov) for the Medicare ACO program, which was created in response to passage of the Patient Protection and Affordable Care Act.
"The AAFP recognizes this proposed regulation as the first major health delivery reform initiative following the passage of the Affordable Care Act," said Heim. But, she noted, the program needs to be improved to ensure that family physicians and other primary care physicians can play an integral role in ACOs.
In particular, the AAFP urged CMS to
- create alternative policies to allow primary care physicians to participate in multiple Medicare ACOs;
- employ a variety of payment approaches, such as blended fee-for-service payments and episode/case rate payments;
- outline quality reporting requirements for the full three-year program and reduce the number of required quality measures;
- offer greater program flexibility to encourage small and medium-sized primary care practice participation; and
- ensure that primary care physicians hold top leadership positions in ACOs.
The AAFP also asked Berwick to retain only those measures that improve population health outcomes and efficiency.
Heim expressed concern that only established integrated health systems with large amounts of capital would have the means to qualify as an ACO based on the proposed regulations.
CMS must attract small and medium-sized practices to the ACO model, or the agency "will squander this tremendous opportunity to improve the health care delivery system and will deny the potential benefits of the ACO model to patients throughout the country," said Heim.
In addition, "CMS' concern with the minutiae of ACO governance and management structure and marketing seems misplaced," noted Heim.
She also urged CMS to think beyond the agency's traditional fee-for-service payment methodology. Employing the usual payment approach would not offer physicians sufficient financial incentives to motivate them to improve the coordination of patient care, said Heim.
"The incentives derived from potential shared savings -- which the Medicare ACO may or may not receive many months after clinical care is provided -- will be small in relation to the fee-for-service payments derived from visits or procedures," said Heim.
The best way to modify physician behavior -- a considerable challenge for any ACO -- is to pay physicians in a timely manner for their services, whether those services are provided directly in a physician's practice or via e-mail or telephone consultation, said Heim.
The AAFP also encouraged CMS to provide estimated expenditure benchmarks before an entity formally applies for ACO status so that participants can make informed business decisions. "Without access to recent Medicare claims data or knowledge of how beneficiaries will be assigned to ACOs, potential Medicare ACOs are unable to estimate their expenditure benchmarks," said Heim. "This inability to determine potential Medicare shared savings will further discourage initial participation."
Regarding quality measures, Heim said asking ACOs to report on 65 measures during their first year was "onerous and operationally unrealistic." CMS' Physician Quality Reporting System only required three measures, and "the response to that program has not been overwhelming," she pointed out.
"Quality measures reporting must be handled with great care and must yield accurate, timely and actionable data," said Heim, adding that the value of such measures is to "provide timely and actionable feedback to the Medicare ACO and its participating physicians so that they can then modify practices, behaviors and systems."
According to Heim, the Academy also has concerns about the proposed quality measure scoring process, the overall performance score, the performance benchmarks and the minimum attainment level for each quality measure. "These types of complexities further exclude smaller and less-integrated primary care practices," she said.
Heim also noted that the law requires the participation of primary care professionals and added that CMS must narrow its definition to only include general internal medicine, general practice, family medicine and geriatric medicine. "The AAFP recognizes that some subspecialists occasionally provide some primary care services," said Heim. "However, they are not providing continuing and comprehensive primary health care to their patients."
Furthermore, the AAFP is opposed to assigning beneficiaries to Medicare ACOs based only on a select set of primary care services provided -- rather than the distinction of the physician specialty -- because doing so "increases the likelihood of assigning beneficiaries to a specialist instead of a primary care physician," said Heim.
She also reiterated the AAFP's position that primary care physicians should be allowed to participate in more than one ACO because doing otherwise "offers very little incentive for even the most sophisticated primary care practice to pursue Medicare ACO participation."
In addition, said Heim, rural family physician practices will encounter additional challenges with Medicare's ACO proposal. She asked that CMS consider special payment incentives, start-up grants and low-cost loans to entities wanting to create ACOs in rural areas.