ACOs Top List of Concerns at Family Medicine Conference

The government's proposed regulations for accountable care organizations, or ACOs, were a top concern among attendees at the 2011 Family Medicine Congressional Conference here on May 9. Many attendees were worried about how the model would affect family medicine and their practices, but AAFP President Roland Goertz, M.D., M.B.A. of Waco, Texas, was quick to remind them that they have an important role to play in health care reform.

The Patient Protection and Affordable Care Act emphasizes prevention and wellness, which puts primary care and family medicine in a position to drive systematic and sustained changes in how care is delivered and paid for, noted Goertz during the conference, which is jointly sponsored by the AAFP and the Council on Academic Family Medicine.

Even as Congress is riven by partisan strife regarding the Affordable Care Act, "we have a message that can cut through (the bickering) because we can offer, at least in the health care arena, something (Congress) can do," Goertz told the nearly 200 family physicians, medical students and state chapter officials attending the conference.

He urged meeting participants to "think about the core message that represents family medicine and how we take care of patients. That is the message that cuts through it all."

The "whole notion of primary care (and) the place of family physicians in our delivery system has swung front and center," said former Rep. Earl Pomeroy, D-N.D. "Your profile has never been higher.

Still, CMS' proposed Medicare ACO rule, which is in the commenting phase until June 6, was a concern for many attendees. FP Paul Lazar, M.D., of Flint, Mich., described the proposed regulation as "very complicated." In the final analysis, ACOs could shortchange physicians and their patients, said Lazar during a session on ACOs presented by Jonathan Blum, deputy administrator of CMS and director of the Center for Medicare Management.

ACOs are a key part of the Affordable Care Act, said Blum, but he stressed that participation in the organizations by physicians and other providers is voluntary.

However, one of the overriding goals of the Medicare ACO program is to encourage lots of different organizations to participate, Blum said. "Our notion here is not to think one size fits all, but to encourage all kinds of organizational models to come into the program," he explained. This includes large and small physician practices, integrated delivery systems, and hospitals that employ physicians.

Organizations have the option of participating in the shared savings program through one of two tracks. The first track involves a two-sided risk, meaning the ACO shares in the savings achieved by the shared savings model, but is accountable for losses as well. The second track is a one-sided risk model in which the ACO shares in the savings but is not responsible for any loses for the first two years of the program.

"We wanted to provide new organizations with a more comfortable on-ramp for two-sided risk," said Blum. But, he added, "Our principle is that all organizations by year three are operating at two-sided risk."

Blum noted that, as currently proposed, ACO regulations would require participating entities to report on 65 different quality measures in five patient quality domains. However, he added, "We're already hearing concerns that this is too many measures, too aggressive. We hear those comments, but at the same time, we want to make sure that the (program) not only saves Medicare money but also elevates the quality of care that our beneficiaries receive."

Family physician Stephen Albrecht, M.D., of Olympia, Wash., asked Blum if he could be retroactively assigned a patient who had already received expensive and, possibly, unnecessary care from subspecialists.

Yes, said Blum, adding, "It gets complicated with how you assign patients -- how you think through all the different ways they touch the health care delivery system."

The hope is that patients will recognize that their care is better managed and delivered through the ACO and, in turn, will want to continue receiving care through an ACO, instead of seeking care from disparate providers and venues.

AAFP President-elect Glen Stream, M.D., of Spokane, Wash., asked Blum to clarify a statement he made about antitrust provisions intended to protect private insurers from the aggregation of physician practices. "I am curious why health insurance plans -- which enjoy protected status as large conglomerates in many parts of the country -- why do we try to protect them when physicians don't have adequate rights to aggregate for purposes of negotiating with those private insurers?" asked Stream, sparking audience applause.

According to Blum, if it is not structured carefully, the Medicare ACO program could lead to broader hospital consolidation and dominance. The antitrust laws represent a "balancing act" -- an attempt to create strong incentives for the creation of ACOs and, thus, better care coordination while blocking attempts by hospitals to use ACOs as a means for achieving market dominance, said Blum.