The AMA House of Delegates has adopted principles regarding the establishment and operation of accountable care organizations, or ACOs, at a time when recently enacted health care reform legislation mandates such shared savings programs with the goal of attaining higher-quality care at lower costs. The action comes nearly a year after the AAFP adopted a similar set of principles.
In adopting the list of principles, delegates to the 2010 interim meeting of the AMA House of Delegates, Nov. 6-9 in San Diego, advised physicians to "make informed decisions before starting, joining or affiliating with an ACO."
They also asked the AMA to develop a toolkit that provides physicians with best practices for starting and operating an ACO, including how to develop governance structures, organizational relationships, and quality reporting and payment distribution mechanisms.
The AMA's ACO principles set forth guidance on what constitutes an ACO and list various features that should be incorporated into such agreements, noting in particular that they must be physician-led, allow flexibility in payment mechanisms and be completely voluntary. The principles also note that interoperable health information technology and electronic health record systems are key to the success of ACOs.
Resolution 819, which was submitted by the California delegation, was one of five resolutions on various aspects of accountable care and ACOs that delegates considered. In one of its resolved clauses, Resolution 819 laid out a set of ACO principles similar to -- albeit more detailed than -- those the AAFP announced last year.
Although the Reference Committee on Medical Service, Medical Practice and Insurance recommended referral of all five resolutions, the report(www.ama-assn.org) the committee issued after a Nov. 7 hearing noted that those who testified on ACOs "consistently spoke of the need for additional information regarding how bundled payments and other payment reforms might be implemented and how their implementation will affect physicians and their practices."
In general, the committee report noted, "testimony on these resolutions reflected a general anxiety about the rapidly changing environment of payment and delivery reforms."
The report also stated that the AMA's Council on Medical Service is preparing information for the 2011 annual meeting of the AMA House of Delegates on bundled payment and other evolving payment and delivery systems that would address concerns raised in the referred resolutions.
Referral, the committee report said, "will provide an opportunity for the development of thoughtful and cohesive policy statements and directives that will help our profession navigate these new challenges and opportunities."
In the end, however, AMA delegates adopted Resolution 819 with only minor amendments. The four related resolutions were referred to the Council on Medical Service.
Glenn Loomis, M.D., of Crestview Hills, Ky., an AAFP delegate to the AMA, attended the reference committee hearing that considered the ACO resolutions. He told AAFP News Now after the meeting that the principles address the needs of family physicians in the current health care reform environment.
"I think the general consensus is that hospitals are taking the lead and going full tilt toward ACOs, and the physicians felt they need some guiding principles when they discuss ACOs with hospitals," he said.
"I do think they really just added detail around the same ideas as the AAFP's principles," he added.
Delegates also adopted recommendations included in a report on financial aid programs from the AMA Council on Medical Education.
According to the council's report, the average medical school debt is increasing, as is the proportion of graduates with debt greater than $200,000. In light of these statistics, said the report, all resident physicians and fellows should have access to the federal Public Service Loan Forgiveness Program(www.studentaid.ed.gov).
The report recommends that the AMA, "through the advocacy process, explore the possibility of assuring that all resident physicians and fellows have access to the Public Service Loan Forgiveness Program for the time they are in residency and fellowship training."
It also recommends that the AMA continue to monitor the short- and long-term impact of the economic environment on the availability of institutional and external sources of financial aid for medical students, as well as on their choice of specialty and practice location.
According to the report, institutional funding as a source of financial aid, as well as medical school revenue from gifts and endowments, has been declining. Recent legislation eliminated the economic hardship deferment known as the 20/220 pathway, which allowed medical students to defer payments on student loans without accruing interest. This elimination also affected access to, and repayment of, student loans.
The pathway was replaced by an income-based repayment process.
According to the Council on Medical Education report, the Public Service Loan Forgiveness Program, which resulted from passage of the College Cost Reduction and Access Act of 2007, allows individuals employed in the public service sector to be forgiven the balance of their eligible student loans after 120 payments have been made.
Although the legislation does not specifically mention physicians, it is likely that physicians employed in settings that provide public service, including residents in nonprofit hospitals and full-time medical school faculty members and other physicians employed full-time in public hospitals or other nonprofit health care settings, would qualify.
In other medical education matters, delegates adopted resolutions that asked the AMA to
- encourage teaching hospitals and other clinical clerkship sites to allow medical student access to patients' electronic health records and to study current barriers to such access;
- oppose any efforts by the federal government, including the Department of Labor's Occupational Safety and Health Administration, to regulate resident education and training, as well as resident and fellow duty hours; and
- oppose tuition taxes and other attendance-based taxes by any government entity.