Although the Affordable Care Act allows hospitals employing physicians and other non-physician professionals such as advance practice nurses, physician assistants and nurse practitioners, to be eligible providers for an ACO, only primary care services provided by primary care physicians matter in determining the beneficiaries that would be assigned to an ACO. And only those ACOs that have been assigned at least 5,000 beneficiaries are allowed to participate in the Medicare Shared Savings Program.
The definition of “primary care physicians” include only physicians with a designation of internal medicine, geriatric medicine, family practice and general practice. Primary care services are defined as a set of services identified by these HCPCS codes: 99201 through 99215; 99304 through 99340; and 99341 through 99350. Additionally, Welcome to Medicare visit (G0402) and the annual wellness visits (G0438 and G0439) are considered primary care services for purposes of the Shared Savings Program.
But many specialists, such as cardiologists, endocrinologists, neurologists and oncologists, are often the principal primary care providers for elderly and chronically ill patients. Surprisingly, neither these specialists, nor the services they provide, would be considered for purposes of beneficiary assignment in the ACO Shared Savings Program.
This approach is different from the PGP demonstration that includes outpatient evaluation and management services provided by both primary health and specialist providers. CMS appropriately identifies its concerns over this assignment methodology. First, excluding specialists that act as primary care providers for beneficiaries would make it difficult for certain ACOs to meet the 5,000 beneficiaries requirement. However, CMS does not think specialists should be required to be “exclusive” to an ACO if the primary care services provided by these specialists were to be counted for the assignment of beneficiaries purposes. As such, CMS is inviting comments on this provision.
Although CMS has laid out many good reasons for only counting primary care services provided by primary care providers, this methodology is likely to encourage ACOs to require or strongly encourage beneficiaries to choose a primary care physician within the ACOs even though the care for those beneficiary has traditionally been provided by specialists.
Also, certain primary care physicians may not be willing to refer beneficiaries that have developed chronic conditions during the contract period to specialists, or insist upon perhaps unnecessary interfacing, for fear of ACOs falling below the threshold of 5,000 beneficiaries. This would not only add an extra layer of services, but also create unnecessary tension between primary care physicians and specialists. Leaving specialists out of the beneficiary assignment process completely does not give enough credit to the role played by these specialists in the care delivery system. CMS should consider how to include primary care services provided by specialists in beneficiary assignment so specialists can also be properly incentivized to manage and coordinate the care to be delivered to this population.