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CMS Administrator Dr. Donald Berwick
Berwick

We can have it all


By CMS Administrator Dr. Donald Berwick
Posted: May 17, 2011 - 1:00 pm ET
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American healthcare is at a crossroads. Thanks to the Affordable Care Act, we are now well en route to assuring that all Americans have the peace of mind that comes with access to healthcare insurance. Thanks to the new law, insurance companies won't be able to deny coverage based on pre-existing conditions, seniors will have access to important preventive care, and health insurance will become affordable through “exchanges” to people who otherwise couldn't afford it.

But better coverage isn't enough. We also need better care. The reason is simple: In its current form, American healthcare is not sustainable, either for many of the people who already have insurance or for the tens of millions who now will be newly covered. It is too often fragmented, uneven in its quality and unsafe for patients, all of which raises costs and degrades care at the same time.

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I am absolutely certain that we can have what we want and need—better care, better health and lower costs—all at the same time. But we can have that only if we are willing to improve the healthcare system, itself—only if we are willing to change the way we deliver care. If we are willing, then the Affordable Care Act can help. Because it doesn't just extend coverage and provide new routes to health insurance; it also gives our nation new tools for improving the care system.

One of those important new tools is the so-called accountable care organization. The idea of the ACO is to encourage and support physicians, hospitals and other providers to lower costs by providing better quality care, and to reward them for success by allowing them to share in the resulting savings. ACOs are part of an important agenda of change: to shift American healthcare from a system based on the volume of care (the more you do, the more you get paid) to one based on the results of care (the better you do for patients, the more you get paid).

ACOs won't just be a new way to pay for care; they will be a new and better way to deliver care.

In late March, the CMS published its initial, proposed rule on how to implement ACOs, and we are now in the midst of a public comment period. We've heard from hospitals and physician groups about their concerns related to the need for capital, shared savings and reduced complexity. We also know consumers want choice and quality. We are listening to these comments, taking them seriously and working to improve the proposal into an even better final rule.

That's a challenging job, because the ground rules for ACOs have to strike several careful balances. We want to give providers incentives to achieve savings and tools to help coordinate and improve care, but we also want to make sure that they don't stint on care or withhold care when it's needed. We want to make sure that patients get far better coordinated care, but we don't want to burden ACOs with rafts of cumbersome regulations. We want ACOs to form close relationships between primary-care providers and specialists, but the Affordable Care Act requires that patients in ACOs retain the right to see any Medicare provider they want. ACOs need data, but patients need their privacy protected. The CMS and our partner agencies have been holding feedback sessions and soliciting input from all stakeholders—physicians, hospitals, patient advocates and many more—on the proposed rule, so that we can get these balances right.

Meanwhile, we're moving ahead quickly. Even as we continue to seek input on the ACO proposal, we are launching several initiatives to allow us to hit the ground running. Providers who are already ahead of the pack in coordinated care will have an accelerated pathway to becoming ACOs even before the new regulations go into effect, thanks to a Pioneer ACO program just announced by the CMS's new Innovation Center. We are seeking comments on a proposal to provide some up-front payments to providers who want to form ACOs but lack access to capital to invest in new infrastructures and staff to coordinate care. And the Innovation Center will soon launch a program of instruction and technical support to help newcomers who want to form ACOs learn how to do so.

As we navigate toward a final version of the ACO design, we are impressed by the level of engagement on this topic; people sense that we are at the threshold of an important and productive change. And, as difficult as it is, coming up with a workable, promising framework for ACOs based on stakeholder feedback will be well worth the effort, because, if implemented correctly, ACOs will be a driving force in improving health and lowering costs. They will be one key to sustainable, high-quality care for all of us.

Dr. Donald Berwick is the administrator of the CMS.


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