Proposed ACO Rules Attract Public Gripes

Cheryl Clark, for HealthLeaders Media , June 9, 2011

• Many ACO candidates seeking to build "the most comprehensive ACO models...are most likely to be ensnared in an uncertain, unappealable, burdensome and costly antitrust review before their merits as a force to transform healthcare delivery can be determined by CMS."

For example, any potential ACO in a metropolitan statistical area that includes the largest hospitals and any other hospital would undergo this review, as would any combination of the second and third largest hospitals.

The American Nurses Association weighed in as well in its rebuke of CMS for having "a blind spot" in its failure to "properly identify and measure nursing services or provide sufficient incentives for care coordination, a core part of registered nursing practice."

And, ANA said, technical aspects of the rule could "prevent patients from choosing advanced practice registered nurses as their primary care provider" because the ACO model requires physicians to head them.

ROUNDS: The Real Value of ACOs August 16, hosted by Norton Healthcare. Register today for this live event.

The inability of a nurse practitioner or physician's assistant to bill under the ACO model – a function assigned only to a physician – was a repeated concern in many letters to CMS.

The American Telehealth Association criticized what it called "formidable statutory restrictions for telehealth services" under Medicare A and B that could have been waived under this proposed rule, but were not. 

The agency should waive certain prohibitions to allow health services by video conferencing for 35 million Medicare beneficiaries who live in 1,092 metropolitan counties, the association said.

It should also permit telehealth services originating from a Medicare beneficiary's home, hospice, dialysis facility, or even a federally funded Indian Health Services facility, or "anywhere else from which a beneficiary seeks service" and to allow beneficiaries to receive physical therapy, occupational therapy, speech-language pathology and audiology services through telehealth systems. Apparently this is not now allowed in the proposed rule.

Bi-State Primary Care Association
James Zibailo, coordinator with the Bi-State Primary Care Association of Vermont and New Hampshire said his organization supports the effort to improve quality of care and reduce costs.

"However, the proposed CMS rule on the Medicare Shared Savings Plan excludes health center-formed accountable care organizations. In addition, it excludes Medicare patients of safety-net providers (such as federally qualified health centers, FQHC look-alikes, and rural health centers) from the shared savings program. The end result is the exclusion of some of the most underserved, at risk patients, who are most likely to benefit from the improved health outcomes associated with participation in the ACO."

ACOs and Drug Treatment Programs

Keith Urban, director of the Yamhill County Chemical Dependency Program in Oregon, weighed in with a concern that drug treatment programs have been left out of the equation. Substance abuse "is a very significant healthcare cost driver," he wrote. Cuts to substance abuse treatment, he said, "invariably reduce the cost savings derived from substance abuse treatment. The rest is politics."

It is sometimes said in life that the mark of a good proposal is one everyone finds some reason to dislike. 

With the exception of those early adopters approved for the Pioneer piece of the ACO rules, those organizations that apply for and are approved for the Medicare Shared Savings Program, known as the accountable care organization, will officially launch Jan. 1.

See Also:
Impact Analysis: Leaders Respond to Proposed ACO Regs
ACO Concerns Elicit Enticements from CMS
CMS Plans ACO Learning Sessions
In an ACO, Who's Accountable?



Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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