Dr. Jerry Penso, medical director of quality programs for Sharp Rees-Stealy Medical Group in San Diego, said his main concern is achieving the 65 quality measures in the proposed rule. “My overall plea is to be more lenient,” Penso said of the measures, which must all be reported to the CMS in the first year, according to the proposed rule.
Sharp HealthCare has been doing accountable care for many years, and last month announced a new program with Anthem Blue Cross of California to conduct an ACO initiative with patients in preferred provider organizations.
Sharp already must report on 80 quality measures for pay for performance, 25 for the Anthem ACO, 65 for Medicare Advantage and 20 or more for the Healthcare Effectiveness Data and Information Set, among other programs it is engaged in, Penso said. “One of the sad things is they don't line up,” he said. He estimated that Sharp is already doing between one-third and one-half of the measures proposed in the CMS ACO rule.
“If this hurdle is too high as far as startup investment costs, I think that would be a barrier for providers,” Penso said.
The Carilion Clinic is one of five sites nationwide participating in a three-year ACO pilot conducted by the Dartmouth Institute and the Brookings Institution. The CMS proposed rule is “very close in concept with what Brookings has envisioned as an ACO,” Lorton said.
Providers that have already done the groundwork to become more accountable for patient quality and cost are likely to be in good shape in many critical areas, Lorton said. For instance, the CMS proposed rule requires that at least half of primary-care physicians participating in the ACO to be in compliance with meaningful-use provisions on electronic health records by the start of the second year of participation.
At Carilion, all the participating physicians are already in compliance with these rules because they work across a standard electronic records platform, Lorton said.
However, the proposed federal antitrust policy for ACOs could prove to be onerous. The U.S. Justice Department and the Federal Trade Commission propose creating market-share thresholds. Although ACOs with up to 30% of local Medicare fee-for-service business would enjoy a safety zone from antitrust scrutiny, collaboratives with 50% or more would be scrutinized.
Data for physician services to determine market clout is lacking in some states, including Virginia, Lorton said. Some providers might not know where they stand until after the review, at which time they might miss out on key deadlines for shared savings participation, he said.
Another issue bedeviling some providers is how Medicare beneficiaries will be assigned to the ACOs. The CMS is proposing retrospective assignment, which means assigning patients based on where they receive care in the first year of the ACO. But this could make planning and coordination more difficult, Penso said. Sharp currently does prospective assigning, so the system knows upfront who the enrolled patients are and what their care challenges may be.
“Justifying costs from a business perspective makes more sense if you have a defined population,” Penso said. “If it's retrospective, it's challenging to budget for that.” The main concern about a prospective model is that patients with fewer acute-care needs might get less attention than those who are at high risk of costing the providers money, according to the CMS.
Penso said he would also like to see the CMS conduct outreach and education to beneficiaries about ACOs because Medicare is considered a trusted source.
Still, other providers said they are not concerned the proposed rule will change the way they do business. Hill Physicians Medical Group, an independent network of 3,500 physicians and other providers in San Ramon, Calif., is part of several ACOs in Northern California, including one with the California Public Employees' Retirement System, one of the largest healthcare payers in the nation.
“The regulations are in many ways a reflection of what we've been doing,” said Dan Robinson, Hill's chief administrative officer and vice president of corporate services.