Another crop of prominent healthcare chief executives emerged last week to publicly snub Medicare's plans for accountable care.

Accountable care organizations, one provision to overhaul health financing under the Patient Protection and Affordable Care Act, would offer possible bonuses or penalties to providers based on quality and health spending targets, under proposed rules.

In a letter to Dr. Donald Berwick, CMS administrator, more than a dozen CEOs from U.S. hospitals and health systems echoed other recent criticisms of the draft rules.

Aurora Health Care, which owns a dozen Wisconsin hospitals, won’t apply to test accountable care under Medicare without significant changes to the proposed rules, said the Milwaukee-based system’s President and CEO Dr. Nick Turkal, one of 17 executives to sign on last week’s letter. “Collectively and as individuals, we felt like there were more barriers that were put up than there were barriers that were taken down,” Turkal said.

The draft rules pay too much attention to process, regulatory regime and provider risk at the cost of achieving better care and lower costs, said the executives, members of a coalition known as the Academy Advisors.

Hospitals and doctors do not know which Medicare patients will be tied to performance payouts until after the fact under the proposed rule. “Other successful capitation models are based on both the patient and provider understanding the relationship,” the letter said. William Leaver, president and CEO of Iowa Health System, who also endorsed the letter, said hospitals cannot monitor performance or make needed changes to improve without timely information about patients enrolled in the accountable care group.

Bonuses proposed by the CMS are too difficult to achieve, capital costs too high and payouts too small, the letter said. Officials should also continue to work with antitrust and fraud and abuse enforcement to allow providers to participate, the letter recommended, and the CMS should gradually introduce quality measures rather than require 65 proposed for the first year, which the letter described as “a substantial practical constraint.”

Not everyone considers the CMS’ proposed demands too rigorous. Paul Ginsburg, an economist and president of the Center for Studying Health System Change, in the New England Journal of Medicine last week, argued the CMS should consider its criteria carefully before responding to criticism. The demanding criteria signaled federal officials’ desire to boost quality and lower costs, Ginsburg said.

“CMS shouldn’t be too quick to lower the ACO bar too far: The initial ACO opportunity should not be for everybody,” he wrote.