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Medicare ACOs Move Closer to Commercial Model Under Final Rule

Margaret Dick Tocknell, for HealthLeaders Media, October 21, 2011

The final regulations also reaffirm certain features of Medicare ACOs, says Sharon Siler, director of healthcare networks for Washington, D.C.-based Avalere Health.

The added good news for health plans is that the features align with many of the operational functions, and management tools and processes that health plans already have in place, such as:

  • Quality assessment. The final rule reduces the proposed measures to assess quality. Instead of meeting 65 measures in five domains, the ACOs will need to meet 33 measures in four domains. Most health plans already have robust quality reporting programs in place to support the collection, aggregation and reporting of data on a real time basis.
  • Health and disease management. Commercial health plans have been promoting disease management for years and already have in place successful programs that providers can use to improvement outcomes for chronic illnesses such as diabetes and heart disease.
  • Data analytics. Siler termed managing financial risk as the "bread and butter" of health plans. "They have the numbers to help providers understand what is happening to their finances and why."

On the flip side, Siler says health plans need to be concerned that the new rules may weaken antitrust protections. She explains that the proposed rules issued in April 2011 required all ACOs to participate in an antitrust review as one way to ensure that an ACO wouldn't limit competition by dominating a market and having an adverse affect on reimbursement rates.

The final rules make the antitrust review voluntary. Siler says that means there will not be a way to stop providers from being so large that they shift the balance of financial power completely to their side. "Payers and employers are very worried that this will create a situation where they have no control over costs," she said.

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