Instead of just singing the “Look What They've Done to My Song, Ma” blues, the AMGA may leave the agency standing on stage by itself. AMGA President and CEO Donald Fisher told Modern Healthcare the organization may turn its focus to the private sector if the CMS doesn't address its concerns and is talking with America's Health Insurance Plans, the trade group representing the nation's largest insurers, to develop a commercial-payer ACO model.
The AMGA often takes credit for getting the ACO concept into the Patient Protection and Affordable Care Act. Its membership consists of 390 large, multispecialty medical groups in which 117,000 doctors practice, and these groups are considered by many to be the prime candidates for forming the nation's first Medicare ACOs.
But in the letter to Berwick, Fisher said a survey of its members found that 93% would not enroll as an ACO under the current regulatory framework. “Our membership's concerns were many and focused on issues such as the risk-sharing requirement, static risk adjustment, retrospective attribution, quality measurement requirements, the minimum savings requirements and others,” Fisher wrote. “Without substantial changes in the final rule, we fear that very few providers will enroll as ACOs and that CMS and the provider community will miss the best opportunity to inject value and accountability into the delivery system.”
Despite its displeasure with the CMS framework—which is described in the letter as “overly prescriptive, operationally burdensome”—the AMGA is not about to abandon the ACO concept. “We're looking to continue to move forward, but to focus much more on the commercial side and work more with AHIP now than on the federal government side,” Fisher said in an interview.
AHIP spokesman Robert Zirkelbach said everything is still in the preliminary stages, but that his organization's participation would have two components: creating partnerships and strengthening advocacy efforts. “We can facilitate health plans partnering with providers who are looking to develop ACOs,” he said. “The AMGA can identify providers who are ready and we can identify the health plans.”
He added that if health plans and providers spoke together, it's more likely the CMS will hear them. “If we work together to identify common themes, we can share them in our comments to regulators and have a common front on key issues,” Zirkelbach said.
In his letter to the CMS, Fisher said that if ACOs are not successful, “draconian cuts across the provider spectrum” may emerge as the only alternative to delivery-system reform.
The 10 participants of the CMS' five-year Physician Group Practice Demonstration sent a similarly negative letter to Berwick, warning that without changes, none would participate.
The signatories—which include Geisinger Clinic, Danville, Pa.; Marshfield (Wis.) Clinic; and Dartmouth-Hitchcock Health, Lebanon, N.H.—said they “all have serious reservations about the economics and the complexity” of the proposed framework for Medicare accountable care.
The letter cites the downside risk during the initial three-year term, compounded by significant investment cost. Physicians and hospitals would be eligible for bonuses or penalties based on quality performance and cost control. On average, according to the letter, it costs $30,000 to program a single quality metric. That means the 60 metrics proposed by the CMS would equate to an investment of about $2 million.
Formal comments on the proposed rules are due June 6.
—with Melanie Evans