Health plans spar with providers over ACO payment

If all goes as planned, we can expect CMS to issue rules for accountable care organization in the next few weeks.

At that point, the disagreement over how ACOs will be defined likely will rise to a fever pitch. Industry lobby groups already are lobbying for different, sometimes conflicting, features.

If the rules are too soft, Kaiser Health News/Washington Post reports, ACOs may not save money, and could prove to be a financial burden to Medicare. If the rules are too harsh, provider groups already have warned that doctors and hospitals will be reluctant to test ACOs as a new payment mechanism.

"The real risk for CMS is the ACOs are a party they throw that nobody attends, says Dr. Jack Lewin, CEO at the American College of Cardiology.

One area where insurers and providers are on different sides of a debate surrounds the question of whether ACOs should be held accountable for all care provided to their patients, even if the patient goes to an unaffiliated provider.

An ACO should not be held responsible for patients who go elsewhere for care, according to a letter the American Medical Association sent CMS.

The Federation of American Hospitals, which represents for-profit facilities, went further, suggesting ACOs be allowed to select which patients to include in their ACO.

Health insurers offer a totally different perspective. They want ACOs to be held accountable for all care given to their patients, even when a patients goes to a provider who is not part of the ACO. "While it may be challenging for ACOs to effectively influence patient care provided outside the ACO network, doing otherwise would defeat the key goals of ACOs, which are focused on comprehensive, patient-centered care," the major industry lobby group, America's Health Insurance Plans, wrote, according to KHN.

To learn more:
- here's the Kaiser Health News/Washington Post story
- here's the AMA's letter to CMS
- here's the Federal of American Hospitals' letter to CMS

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