Doc groups stuff ACO suggestion box with complaints

The public comment period for the Center for Medicare & Medicaid Services' (CMS) proposed rule regarding accountable care organizations (ACOs) closed June 6, and major organizations that represent physicians made sure to contribute their thoughts. Overall, the regulations get a big thumbs-down from physicians, who say that the proposal is too restrictive and doesn't involve enough financial incentives to encourage practice participation.

The American College of Physicians (ACP), for example, stated in a 10-page letter addressed to CMS Administrator Donald Berwick that although it supports the primary-care focus and patient-centered intentions of the proposed rule, the regulations as written would require internal medicine physicians, particularly those in small practices, to assume too much risk. The letter, therefore, suggests that CMS create a "laddered" pathway to ACO participation for practices of different sizes to make varying degrees of transformation. The College also recommends participants not be required to share in any financial losses incurred by the ACO.

Similarly, the American Academy of Family Physicians' (AAFP) Board Chair Lori Heim, MD, agreed that the proposed regulations were biased toward established integrated health systems with large amounts of capital. Heim's letter also encouraged CMS to consider a variety of payment approaches, such as blended fee-for-service payments and episode/case rate payments.

Formal comments from the Medical Group Management Association's (MGMA) offered specific recommendations as well. For example, MGMA recommends patients be assigned to ACOs on a prospective basis and ACOs have the ability to exclude certain patients unlikely to receive the bulk of their care within the ACO.

The American Medical Group Association (AMGA), while also stating that it wanted ACOs to work, offered expansive suggestions to overhaul the rule. As also indicated by other groups, AMGP says it wants to see only a shared savings risk assumption, more shared savings available to providers, and fewer required quality measures, which would be phased in over time. Other key ideas provided in the letter written by AMGA President Donald W. Fisher, PhD, CAE, include, among several others, allowing ACO participants to elect retrospective or prospective patient attribution and lowering the minimum savings rate to 1 percent.

The American Medical Association (AMA) also recommended many of these and similar changes. Its 31-page comment letter authored by Michael D. Maves, MD, MBA, called for CMS to pay for telephone calls with patients and other non-face-to-face encounters as a way to reduce overall expenditures for Medicare. In addition, the AMA says it wants CMS to issue an interim final rule allowing the regulation to be modified as lessons are learned.

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