In response to widespread objections from doctors and hospitals to proposed federal rules on accountable care organizations, CMS director Don Berwick, MD, Tuesday introduced three programs designed to woo providers to apply for the new payment model.
The effort strives to "help early comers get started sooner, help novices learn faster, and help those who need a little bit of assistance to capitalize their effort," Berwick said in a news briefing.
The initiatives will allow providers "to hit the ground running," and will "give providers of all sizes and backgrounds the ability to participate in this exciting progress in American healthcare right now."
Initially however, some providers who object to the format required to set up the ACOs said Berwick had not changed their minds, and that much more work needs to be done to reduce the risk and capital outlay requirements.
With the first program, the Centers for Medicare & Medicaid Services is proposing to fast-track about 30 "pioneer" systems, at least to start, that already provide coordinated care. They would get a speedy way to participate in the shared savings program by September or October rather than having to waiting until Jan. 1.
The administration says that those in the pioneer model alone will save Medicare "as much as $430 million over three years by better managing care for beneficiaries and eliminating duplication."
Previously, the administration estimated three-year savings from ACO participation of between $510 million and $960 million.
The names of the 30 candidate systems were not released.
In a second deal sweetener, the administration might provide some upfront payment for organizations that lack the millions of dollars in capital necessary to pay added staff and buy equipment to launch an ACO.
"Some of the early comments on the proposed rule suggest that some providers lack the capital they need to invest in the infrastructure, like information systems and staff for care coordination," Berwick said. Under this second option, "providers who lack access to capital could make those investments under the idea of an accelerated payment program by accessing shared savings early."
Organizations now participating in CMS' Physician Group Practice (PGP) demonstration projects would not be precluded from joining in as "pioneers," Berwick said.
"PGP sites are quite suitable in terms of the competence and experience to be pioneers, if they choose to," he said. A link to the "Pioneer" application rules and procedures is here.
The agency is requesting comments from providers on the advance payment model proposal by June 17.
The third enticement comes in the form of education and training. The agency is organizing a series of four free Accelerated Development Learning Sessions, which Berwick says should be useful in giving providers access to knowledge and expertise to set up their own ACOs. The sessions will include explanations on core competencies such as improved care delivery to increase quality and reducing costs and using health information technology and data resources.
Berwick acknowledged the volume of concerns providers have expressed about the first ACO model, saying his agency has been "listening closely to input from all sorts of stakeholders so we can modify and improve the proposed rule into an even better final rule."
But he cautioned that the task is a "very challenging job because the ground rules for ACOs have to strike careful balances in a number of dimensions. For example, they have to give providers incentives to achieve savings, and tools, to help coordinate and improve care.
"We also need to make sure that providers don't stint on care or withhold care when it's needed in pursuit of those incentives."
But Berwick kept the tone upbeat. "People do sense we're on the threshold of an important and productive change and we're coming up with a workable and promising framework," he said.
Some organizations such as Kaiser Permanente have said that they do not plan to apply to become an ACO for their population of Medicare patients because under their current model, they already have the elements of an accountable care and their care would not benefit.
Kaiser CEO George Halvorson has said that Kaiser provides care for its 8.8 million beneficiaries using the essential elements of an ACO right now.
In an interview with HealthLeaders Media last month, he said, "I think the payment structure defined in the ACO regs is an interim step toward getting people to function as an accountable care organization. And I think it is directionally correct. It is not as good as a Medicare Advantage program where you receive full prepayment for the care of the patient. This is a partial prepayment."
It isn't clear whether the Pioneer model might prompt Kaiser to change its mind.
The American Medical Association's immediate past president J. James Rohack, MD, said in a statement that Berwick's alternative proposals Tuesday take "a step in the right direction, but more action is needed to ensure all physicians who wish to do so can lead and participate in Medicare ACOs."
He added that the AMA believes the benefits of ACOs "cannot be fully realized unless physicians in all practice sizes can be involved. According to the AMA physician practice survey, 78 percent of office-based physicians in the United States work in practices with nine physicians or less. The AMA has encouraged CMS to provide assistance for physicians in small practices, including startup capital and small business loans, to meet the large initial expenses that will come with participation in ACOs.
Some other providers also were not persuaded.
Scripps Health CEO Chris Van Gorder told HealthLeaders that the new proposals are unlikely to change his stance, which is to not apply or participate in the ACO demonstration concept.
"The downside is still too risky for a start-up and these elements are not well explained. Would not commit to anything until we saw all the revised regulations and see how these new elements fit with the other revisions. If this is the extent of the changes, the answer would be still no."
Nick Turkal, MD, president/CEO of 15-hospital Aurora Health Care, the largest private employer in Wisconsin, told HealthLeaders that the new offerings CMS unveiled on Tuesday do not address his fundamental concerns about the high risks and low rewards for ACOs under the proposed rules.
Turkal says Milwaukee-based Aurora had hoped to take part in the ACO program, but won't do so unless the proposed rules are significantly changed.
"The fundamental issue is if CMS has proposed a model which is not going to work," says Turkal. "After the June 6 public comment period, are they fundamentally going to change the model or is it going to be just some minor adjustments around the edges? The real answer is that without some fundamental change in CMS' current proposed model, there are not going to be many takers."
CMS intends to run these programs out of the new Center for Medicare & Medicaid Innovation, an entity created by the Affordable Care Act and which is said to be spending $10 billion in an effort to find new ways to pay for and deliver healthcare.