The Centers for Medicare and Medicaid Services (CMS) has released a long-awaited proposed rule that outlines the creation and operation of Accountable Care Organizations (ACOs) that will be eligible for potentially significant Medicare incentive payments in coming years. The Medicare ACO program, as defined by the Affordable Care Act (ACA), is slated to begin on January 1, 2012.
As proposed by CMS, Medicare ACOs are groups of providers of services and suppliers that work together to manage and coordinate care for Medicare fee-for-service beneficiaries. (The program does not extend to patients enrolled in Medicare Advantage plans.) The goal of the ACO program is to provide high-quality care while lowering the growth of Medicare expenditures in the fee-for-service program.
ACOs that successfully meet quality and cost-control measures would share in the savings achieved, which would be divided between the ACO and CMS. Participating ACOs would be required to have an organizational structure that would negotiate and distribute the shared savings among the participating entities within the ACO.
ACO members will continue to receive their regular Medicare Part A and Part B payment for services provided to patients who have been assigned to the ACO. In addition, ACO members would be eligible for a portion of any shared savings bonus that the ACO receives from Medicare if the ACO successfully reaches annual quality and cost-saving goals. However, payment of the shared savings incentive payment will be made by CMS to the successfully-participating ACO, not to the ACO professionals within the ACO. Ultimate distribution of incentive payment among ACO members will depend on contractual arrangements between the professional or facility and the ACO.
Entities eligible to directly participate in a Medicare ACO include:
- Physicians or other "ACO professionals" in group practice arrangements
- Networks of individual practices of ACO professionals
- Partnerships or joint venture arrangements between hospitals and ACO professionals
- Hospitals employing ACO professionals
- Other groups of providers that CMS deems appropriate
The proposed rule defines an "ACO professional" specifically as 1) a physician; 2) a physician assistant; 3) a clinical nurse specialist; and 4) a nurse practitioner (as those terms are defined within the Medicare program). CRNAs are not included in the definition of "ACO professional." Therefore, as proposed, it appears that groups of CRNAs practicing independently would not be eligible to participate in a Medicare ACO shared savings program.
Anesthesiologists and other hospital-based physicians will initially have a limited role in overall Medicare ACO outcomes. In its first iteration, the nucleus of a Medicare ACO is primary care. Each qualified ACO will have at least 5,000 Medicare fee-for-service beneficiaries assigned to it and must have a sufficient number of primary care physicians to care for them. The quality measures proposed for the program focus on chronic disease management (such as diabetes, COPD, and congestive heart failure) and preventive case (such as immunizations and vaccinations). There are 65 proposed quality measures, all of which must be achieved by a successfully-participating ACO in order to qualify for a bonus.
On the other hand, there are two patient safety quality measures to which anesthesiologists may be able to contribute immediately. These are health-care-acquired condition measures, which apply to things such as central line associated blood stream infections (CLABSI), central venous catheter-related bloodstream infections, and post-operative sepsis, all of which incorporate the antibiotic management strategies that many anesthesia practices are providing and documenting already as part of the Medicare Physician Quality Reporting System (PQRS).
CMS expects to add additional measures for hospital-based care in future years, so anesthesiologists may see their specialty play a bigger role as CMS gains experience with the ACO program.
Strategies for Anesthesiologists
As the ACO program begins, anesthesiologists may wish to consider activities such as the following:
- Monitor the evolution of the proposed rule that appears in the April 7, 2011 edition of the Federal Register. It can be viewed here: http://edocket.access.gpo.gov/2011/pdf/2011-7880.pdf. CMS will be accepting public comments on the proposed rule for 60 days following publication. Instructions for submitting comments can be found in the proposed rule.
- Be cognizant of the fact that ACOs developing in the private sector may follow Medicare's lead in many ways when developing their own guidelines.
- Watch for publication of the final rule later this year, which will incorporate any changes that CMS makes following consideration of comments.
- Be prepared for implementation or revisions to electronic medical record software used by the hospital(s) or other facilities in which you practice that may participate in an ACO. The use of electronic medical records to provide shared patient data between all of the ACO professionals and entities participating in an individual ACO will be required. This may be an opportunity for anesthesiologists' input in the development or update of portions of the electronic record that capture and document anesthesia care.
- If the hospitals or other facilities with which you work or contract are positioning themselves to be part of an ACO, consider how your practice can contribute to the early success of the program and thus share in the savings bonus, particularly if the hospital proposes a change to your compensation model based on the facility's ACO participation.
- Understand that your practice's share of any shared-savings bonus from Medicare for successful participation by the ACO will depend on your practice's ability to negotiate with the ACO itself. ACO professionals will not receive payment directly from CMS.
- Know that the way an ACO is structured may implicate antitrust issues and other Federal laws. CMS indicates in the propose rule that the agency has worked with the Office of Inspector General (OIG), the Federal Trade Commission, the Antitrust Division of the Department of Justice, and the IRS to address legal and tax implications of ACO arrangements. In addition, CMS and the OIG have issued a joint notice with comment period outlining proposals for waivers of the physician self-referral law, the anti-kickback statute, and the civil monetary penalty law for ACOs participating in Medicare's shared savings program. Anesthesiologists and other ACO professionals considering participation in a Medicare ACO may wish to consult with legal counsel as part of the due diligence process to verify the ACO's compliance with these multiple complex regulations.
© 2011 Healthcare Reimbursement inSIGHT. All rights reserved. Reprinted by permission of the author. Original publication source: PPMIS Vital Works, April 2011.
Contact Brenda Morrow at (816) 522-7774 or brenda1075@att.net.