In its formal comments (PDF) to the CMS on the proposed rule for accountable care organizations, the nation's second-largest doctor organization, the American College of Physicians, offers support for the rule's intent but expresses concern that the proposed rule "sets too high a bar for participation" for smaller, independent practices.
"The required administrative, infrastructure, service delivery and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure"—those that already have "ready access to capital, substantial infrastructure development and experience operating under an integrative service/payment model," Dr. Don Hatton, chairman of the ACP's Medical Practice and Quality Committee, wrote in a letter to CMS Administrator Dr. Donald Berwick. "Even these entities have questioned the 'business case' for adoption of the ACO model as outlined in the proposed rule."
Hatton suggested that the CMS establish a "ladder" with different entry levels into the ACO program. Levels would be "linked to the service, quality and risk assumption requirements the collaborate entity chooses to accept."
In addition, although the ACP is pleased that the CMS appears to establish primary care as the foundation of ACOs and strongly supports linking the use of defined quality measures to shared savings, the group is concerned that the reporting burden for the large number of measures—65 across five domains—would pose a significant barrier to participation.
There was also disagreement with the CMS' plan for retrospective attribution, in which practices would not know which Medicare beneficiaries had been assigned to them until nine months after the end of the fiscal year. The letter said this plan "is not practical and not consistent with good clinical and business practices."
"We acknowledge the concern that prospective attribution could in theory result in the ACO providing different standards of care to patients who are prospectively attributed to the ACO and those who are not," Hatton wrote. "However, professional ethics and standards require that physicians not provide a lower level of care to one group of patients compared to another; the profession's commitment to its own ethics therefore will mitigate against ACOs providing a lower level of care to patients not prospectively attributed to it."
The proposed rule ultimately "represents an earnest attempt to improve the quality and efficiency of healthcare delivered to our Medicare beneficiaries," Hatton concluded, but because it would involve launching a completely new program, the ACP recommends that—instead of issuing a final rule—the CMS issue an interim final rule to maintain the flexibility needed to amend the rule when needed.
The Philadelphia-based ACP is the nation’s largest medical specialty society with 130,000 internal medicine physician and medical student members.