We’re getting some good traction in the hospital and physician trade press regarding our analysis of the ACO regs. I provided an interview with Physicians Practice discussing the shared savings models of the proposed rules for accountable care organizations and balancing risk versus reward in establishing new health care partnerships. The interview centered on how the … Continue Reading
Providers considering applying to CMS to become an ACO should be aware that the proposed ACO rules are modeled in significant part after Medicare’s Physician Group Practice demonstration project. Five years in the planning and launched in April 2005, the PGP Demonstration included 10 multi-specialty group practices in various regions of the country comprised of … Continue Reading
The Affordable Care Act requires the assignment of Medicare beneficiaries based on which physician provides a beneficiary’s primary care services, and delegates the task of prescribing the assignment methodology to the Secretary of Health and Human Services. After considering a majority rule and a plurality rule, CMS believes that the latter should be the governing … Continue Reading
As discussed previously here, here, and here, antitrust matters are a key consideration in the design of the Shared Savings Program and ACO development. For example, antitrust review of prospective ACOs by the FTC and/or DOJ is a critical aspect of the ACO application process. Despite the release of the joint statement, there is evidence … Continue Reading
Among other reasons, CMS may terminate an ACO from participating in the Medicare Shared Savings Program if the ACO avoids “patients at risk” to reduce the likelihood of increasing costs to the ACO. The Affordable Care Act, however, does not define which patients are at risk. In the recently release proposed ACO rule, CMS proposes … Continue Reading
CMS has considered two basic options for assigning beneficiaries to an ACO to calculate eligibility for shared savings. The first option is that beneficiary assignment would occur at the beginning of the performance year on a prospective basis. The second option is for beneficiary assignment to occur on a retrospective basis based on the actual … Continue Reading
by David Sheon, WHITECOAT Strategies What a week since CMS launched its regulations on ACOs. The complexity of the rules offered little help to journalists seeking to explain the implications to readers. CMS tried its best to help by providing fact sheets for providers as well as for consumers. And while most journalists writing on … Continue Reading
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 … Continue Reading
On Friday, April 8, Peter Pavarini and I co-presented a webinar overviewing the ACO regulations from a legal perspective. We were part of a three-firm “task force” that came together to analyze the rules and provide guidance to our clients and friends. In addition to Squire Sanders, Paul Lee and others from Strategic Health Care and … Continue Reading
In commentary to the proposed regulations, CMS has committed to coordinate with other Federal agencies on various issues that relate to the Shared Savings Program. This includes coordination with the FTC and DOJ (the “Antitrust Agencies”) with respect to antitrust issues. This coordination is shown through CMS’s intention to incorporate the FTC/DOJ Proposed Statement on … Continue Reading
Section 3022 of the Affordable Care Act (ACA) provides for the development of the Medicare shared savings program for accountable care organizations (ACOs). The ACO program is intended to improve care for individuals and health for populations, as well as slow the rate of cost growth. The proposed rule recently released by the Centers for … Continue Reading
Under the proposed ACO rules, CMS will assign Medicare beneficiaries to ACOs based on where the patient receives the “plurality” of their primary care services during the year before the relevant ACO performance measurement period. If medical cost savings can be achieved during the performance period for the ACO’s assigned beneficiaries as compared against the CMS projected benchmark … Continue Reading
By Daniel J. Vukelich, AMDR The acronyms and new terminology alone can be overwhelming: ACO: Accountable Care Organization; SSP: Shared Savings Program; VBP: Value-Based Purchasing; HIT: Health Information Technology; and of course, AMDR: Association of Medical Device Reprocessors. Medical Device Reprocessors? What do medical device reprocessors have to do with ACOs or even healthcare reform for … Continue Reading
For many of us still digesting last week’s ACO manifesto, the first question we must answer is what kind of organization should seek to qualify as an ACO? “In order to implement the statutory requirements that ACOs have a shared governance mechanism and a formal legal structure for receiving and distributing shared payments, we (CMS) … Continue Reading
ACOs who apply for this first wave of the Medicare Shared Savings Program will be shouldering significant risk, especially given the unknowns left after the Proposed Rules were released. Few organizations will be in a position by January 2012 to even apply for participation in the shared savings program, in all probability. Those ACOs that … Continue Reading
I agree with my colleagues that CMS appears to be looking to the industry to guide them on waiver development, as well as other details of the Medicare Shared Savings Program. CMS intends to grant waivers that would apply uniformly to all ACOs, ACO participants and ACO providers/suppliers participating in the Medicare Shared Savings Program. … Continue Reading
The Accountable Care Act permits the Secretary of HHS to implement partial capitation models or any other payment model the Secretary determines will improve quality and efficiency. The Proposed Rule states that the Secretary will test partial capitation models in the Innovation Center. Pursuant to the “other payment model” authority, however, the Proposed Rule would … Continue Reading
Does anyone else feel that the proposed waiver regulations don’t go far enough? Do you think they allow providers to engage in flexible arrangements that deliver value to the government? The key is how the government has limited the waiver proposals mostly only to the shared savings distributions. That seems too narrow, although I think … Continue Reading
The Federal Trade Commission and Department of Justice (the “Agencies”) recently released Proposed Statement of Antitrust Enforcement Policy Regarding ACOs, which contains several points of interest: Rule of Reason Treatment. The Agencies will provide rule of reason treatment to an ACO if, in the commercial market, the ACO uses the same governance and leadership structure and … Continue Reading
By Daniel J. Vukelich, President, Association of Medical Device Reprocessors I’ve been thinking about Robert Pear’s analogy, as he wrote in today’s New York Times that: Until now, accountable care organizations were like unicorns, creatures that flourished in the imagination but proved persistently elusive in the natural world. The rules define the new entity as a … Continue Reading
The proposed CMS rules for accountable care organizations have only been out a few hours and even the speediest readers are still plowing through them, but a few initial observations are in order: CMS is admitting it needs more than the usual amount of public comment to craft final rules. Perhaps this was intentional but … Continue Reading
Several important antitrust points of interest in the hot-off-the-presses ACO regulations issued today: The Department of Justice and the Federal Trade Commission have a new challenge – figuring rules of the road as joint administrators of the ACO antitrust review process, acting through a newly formed joint working committee. The agencies will either have to … Continue Reading
Discussions among physicians and physician groups contemplating the formation of an ACO can raise concerns under antitrust laws, particularly when those physicians or physician groups are considered competitors in the market. In the absence of contradictory guidance in the forthcoming ACO rules, it is important that physicians engaging in such discussions abide by the following … Continue Reading
On March 15, Ohio Governor John Kasich announced his proposal to balance Ohio’s budget (the Blue Book). Because the Ohio budget is in large part reserved for Medicaid, health care changes play a significant role in the new budget plan. Governor Kasich’s budget proposal included establishing pediatric accountable care organizations (Pediatric ACOs). The following discussion outlines the … Continue Reading
