Tag Archives: ACO

Proposed Definition of At-Risk ACO Beneficiaries Leaves Questions Unanswered

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

Prospective or Retrospective Beneficiary Assignments to Calculate Eligibility for Shared Savings

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

The ACO Information Gold Rush: "Accountable Care Organizations" in the News

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

When it Comes to ACOs, Some Primary Care Physicians are More Equal Than Others

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

Squire Sanders Participates in Successful Webinar on ACOs with Strategic Health Care and Plante Moran

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

Taking the Antitrust Policy Statement a Step Further…

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

Two views on Beneficiary Data Implications for Patients and ACOs: Part 2 – ACOs Use of Medicare Beneficiary Identifiable Claims Data to Track Population Health and Expenditures

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

Two Views on Beneficiary Data Implications for Patients and ACOs: Part 1 – Balancing Patient Privacy With the Objectives of the Program

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

Why AMDR and ACOs?

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

Something Old, Something New, Something Borrowed….

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

When it Comes to the Waiver Regulations, Comment Early!

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

Introducing Risk Through a Shared Savings Program: The Two-Sided Model – A Carrot and Stick Approach

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

Proposed ACO Waiver Regulations: Not Far Enough? An OIG Challenge During My Presentation at Friday's AHLA Medicare and Medicaid Institute

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

Antitrust Considerations from the Recently Released ACO Proposed Regulations

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

ACO 101 – Unicorns No More

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

ACO Rules – Initial Observations

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

FTC/DOJ Release Joint Guidance on ACOs

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

Accountable Care Organization Regulations

The Centers for Medicare and Medicaid Services (CMS) and HHS Office of the Inspector General posted proposed regulations and requests for comment to further implementation of the Medicare Shared Savings Program created by the Patient Protection and Affordable Care Act.  In addition, the Department of Justice and the Federal Trade Commission published guidance regarding the antitrust implications of accountable … Continue Reading

Antitrust Guidelines for Physician Discussions Relating to ACO Formation

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

Pediatric ACOs – Helping to Balance Ohio's Budget

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
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