Proposed Rule on CO-OP Program Needs Changes

PCMH Should Serve as Foundation of CO-OPs, Says Academy

October 11, 2011 02:30 pm News Staff

The AAFP once again is calling on CMS to fully incorporate the patient-centered medical home, or PCMH, into an initiative designed to foster the creation of qualified nonprofit health insurance plans in every state and the District of Columbia.

The Consumer Operated and Oriented Plan(, or CO-OP, program resulted from passage of Patient Protection and Affordable Care Act. The program provides loans to help generate consumer-governed, private, nonprofit health insurance plans that can compete in the individual and small-group markets. One of the goals of the program is to create at least one qualified nonprofit health insurance plan in each of the 50 states and the District of Columbia. The Affordable Care Act directs HHS to consider plans that demonstrate private support, are ready to expand statewide and employ integrated care models.

"The AAFP strongly urges CMS to fully incorporate the patient-centered medical home concept into the CO-OP program," said (then) AAFP Board Chair Lori Heim, M.D., of Vass, N.C., in a letter(3 page PDF) sent last month to CMS Administrator Donald Berwick, M.D. "As CMS evaluates CO-OP grant applications, we urge the agency to consider that the reduction in the growth of health care costs, decreased mortality rates, and improved participation in preventive and screening services are some of the many benefits of the patient-centered medical home."

In the letter, which constitutes the Academy's response to the proposed rule from CMS( on the program, Heim also noted that changes to antitrust regulations and to Stark self-referral regulations need to be explored to allow physicians, especially those practicing in small- and medium-sized practices, to fully participate in the CO-OP program.

"CO-OPs, as designed, should significantly increase competition through self-regulation of price gouging by facilities, health systems, labs and (sub)specialists while promoting patient-centered care," said Heim. "The AAFP believes that physicians need clear guidelines on how to satisfy (Federal Trade Commission) policy as greater integration is pursued."

Antitrust laws should not create barriers that inhibit clinical integration, she added.

The AAFP also urged CMS to specify that CO-OP operational boards place primary care physicians in the top leadership positions to ensure that CO-OPs are primary care-driven. "Significant and equitable representation from primary care and specialty physicians in a CO-OP's administrative structure, policy development and decision-making processes will help to ensure the program's success," said Heim.