The AAFP is working to make sure CMS keeps family medicine in mind as the agency writes new rules meant to expand the ranks of accountable care organizations (ACOs), which represent one of the more aggressive attempts to improve patient care.
In a detailed March 23 letter(9 page PDF) responding to a proposed rule on ACO operations, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., offered CMS Acting Administrator Andy Slavitt critical comments on how patients are assigned, data is shared, benchmarks are established and annual performance measures are reported. He expressed optimism that more small and mid-size practices could participate in the shared savings model if data is shared more readily with primary care physicians.
Patients become part of an ACO based on their choice of physician, a policy that AAPF supports. However, Wergin wrote that when determining a patient's participation in an ACO, more weight should be given to the volume of services from one physician over time rather than a single, more recent visit to another physician. The AAFP also recommended that CMS create an appeals process to allow a physician in an ACO to decline a patient based on the patient's utilization history.
The AAFP also said payment for primary care should reflect both the efficiency and diversity of care as family physicians care for patients with multiple conditions. A greater investment in primary care could help reduce more expensive procedures for patients.
- The AAFP told CMS in a recent letter that proposed new rules about accountable care organizations (ACOs) must support primary care.
- Compensation should account for the fact that a typical primary care visit is more complex than a typical subspecialist visit, the letter stated.
- The AAFP also recommended that CMS create an appeals process to allow a physician in an ACO to decline a patient based on the patient's utilization history.
"Primary care will require flexible and creative methodologies to ensure we account for its clinical nuance and accurately measure its value," Wergin wrote.
For example, 55 percent visits made by adults with diabetes to primary care offices involved at least one diagnosis in addition to diabetes, according to recent research(www.primary-care-diabetes.com) from the Robert Graham Center that Wergin cited in the letter. Compensation should account for the fact that a typical primary care visit is more complex than a typical subspecialist visit.
Wergin addressed other concerns about ACO progress, citing a 2015 AAFP/Humana survey that asked family physicians their opinions about value-based payment models.
One major problem with ACO performance data is that it is being collected two years before payment is made, a gap that makes it difficult for physicians to change their practices. Sixty-three percent of family physicians do not receive data in a manner timely enough to improve care or reduce costs, according to the survey.
"The AAFP continues to believe that 2-year old data is not clinically actionable or meaningful, and we implore CMS to explore ways to realistically provide actionable feedback," Wergin wrote.
Primary care physicians would be expected to monitor a patient's overall costs by managing referrals, but that is difficult in the current environment. Physicians in ACOs receive data about costs after a patient receives services, and they do not have data comparing high- and low-cost specialists. Seventy-six percent of family physicians said they do not have information on costs of services for appropriate referrals, according to the AAFP/Humana survey.
"Costs for surgeries, procedures, labs and diagnostic tests should be available to physicians, so they and their patients can make informed decisions on referring patients to specialists, and ordering diagnostic tests and labs," Wergin wrote.
Even as ACOs are meant to facilitate greater care coordination, patients might choose services that a physician did not recommend, or they might choose to see physicians outside their insurance network. CMS did adjust performance measurements to include an updated patient list.
"Physicians should not be responsible for costs they cannot control, and provider accountability for costs needs to be balanced with patient accountability," Wergin wrote. "Patients who leave the ACO participant list should not adversely affect the ACO’s benchmark calculations."
Over the long term, the AAFP recommended that ACOs be evaluated on how they save costs relative to institutions in the surrounding area, not just in comparison to their own past performance.
"Relying too much on historical data forces ACOs to compete against themselves and will ultimately lead to diminishing returns on quality improvement and cost savings," Wergin wrote.
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