Proposed CMS Rule on ACOs Draws Sharp Response From AAFP

February 18, 2015 04:07 pm News Staff

As CMS continues to update rules for participating in Medicare Accountable Care Organizations (ACOs), the AAFP is asking the agency to consider a more flexible approach to assigning patients to ACOs.

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Earlier this month, the AAFP sent a comment letter(5 page PDF) in response to the agency's publication of a proposed rule for physician practices that are participating in the Medicare Shared Savings Program (MSSP).

Medicare patients are assigned to an ACO based on which primary care physician provides the highest volume of their care. Although CMS wants to expand participation in alternate payment models, the AAFP said the agency's policies might have the opposite effect because of this assignment process. Of specific concern: The agency allows primary care physicians to participate in only one Medicare ACO.

"By locking primary care physician participation into only one Medicare ACO, CMS essentially is limiting ACO participation to only a portion of the primary care practice's Medicare patient population," the AAFP letter reads. "This proposed policy reinforces our belief that the regulation offers very little incentive for even the most sophisticated primary care practice to pursue Medicare ACO participation."

Story highlights
  • CMS is proposing a new rule for patient assignments to accountable care organizations (ACOs) that the AAFP said in a letter should be revised to encourage more physicians to participate.
  • Using the new chronic care management physician selection process as a model for assigning patients to an ACO would create a more patient-oriented system, the Academy said.
  • The letter urged CMS to do more to make ACOs and the Medicare Shared Savings Program attractive to small and medium-sized practices.

When assigning patients to a specific ACO under CMS' proposed policy, the patient's primary care physician would be determined retrospectively using claims data showing which physician provided the most primary care. (Notably, CMS created a list of specialties that would be excluded from this initial step, a move the AAFP supported.)

But rather than CMS assigning a patient to an ACO, the AAFP countered that Medicare patients should have discretion to make the selection themselves -- a prospective approach -- and then be encouraged to stay with the same physician and ACO.

A model that uses a more patient-oriented selection process already exists among patients who receive ongoing care for chronic conditions. Beginning in 2015, physicians can bill Medicare for chronic care management services. Patients sign a consent agreement each month attesting that they will not receive the same type of care from another doctor during the period. Physicians can bill the code for the same patient only once each month.

"If CMS allowed patients to prospectively choose their own Medicare ACO with a consent process similar to that of the new chronic care management code, CMS would have a significantly improved, more timely, actionable, and therefore more effective beneficiary attribution method," the AAFP letter reads.

Another point of contention in CMS proposed rule: Medicare patients could be assigned to an ACO based on care they received from a medical professional who is not a physician. The AAFP contends the assignment should be made exclusively according to the primary care physician and notes that claims data are not sophisticated enough to determine whether nonphysicians are practicing independently, in a primary care office, or in a specialist's office.

The resources for providing coordinated care are already in place inside many primary care physician practices. Sixty-eight percent of such practices have health information technology that can help facilitate the kind of care that ACOs promote.

"Family physician practices are best situated to provide coordinated care to Medicare beneficiaries, a fundamental objective of the Medicare ACO program," the letter reads.

According to CMS, a total of 220 ACOs were participating in the MSSP in late 2014. Initial performance results were mixed, with 118 of them reporting cost reductions that led to Medicare savings, according to agency data. In its letter, the AAFP expressed concern that large and established integrated health systems are the only institutions that possess the necessary resources to participate in the program.

"We believe that CMS should do more to attract small- to medium-sized practices, especially in rural settings and in urban underserved areas, to form ACOs and participate in the MSSP," the letter reads.

After a physician practice joins an ACO, the next hurdle is moving from the shared-risk stage to a point where the ACO assumes greater financial risk. In another letter(6 page PDF) sent Feb. 6, the AAFP and numerous other medical organizations urged CMS to move slowly in negotiating that transition, noting that during the first two years, the potential for shared savings is limited.

More From AAFP
Detailed version of Feb. 6 joint letter to CMS(35 page PDF)