Federal officials also dropped measures of patients' experience moving from the hospital to home or nursing home and other care coordination measures.
Nonetheless, Fishman said it's unclear whether changes would be sufficient to attract hospitals. That calculation will be made as each hospital weighs the risks versus the rewards, she said. And that equation also depends on Medicare reimbursement in the coming years, she said. “All of the things that Congress is going to do in the next three years will apply to the ACO,” she said.
Even as medical associations and consumer groups combed through hundreds of pages for the new regulations last week, many reacted to provisions of the rule. The Campaign for Better Care, an advocacy coalition for the chronically ill, applauded the use of patient experience in performance measures but called new rules for patients' role in governance weaker than first proposed. “In the end, we see this rule as a reasonable compromise,” said the coalition's president, Debra Ness.
Not everyone agreed. Leah Binder, CEO of the Leapfrog Group, an employer coalition for healthcare quality, called the final rules “far too cautionary.” Binder called the transparency requirements “anemic” and said quality measures were too weak, failed to focus on outcomes and did nothing to discourage overuse of healthcare services.
She also cautioned that too little transparency would leave consumers unable to drive competition among providers. Health insurers also expressed concern with changes to antitrust oversight of the ACOs.
The Justice Department and FTC said some organizations would no longer face a mandatory antitrust review and the agencies' guidance would no longer be limited to ACOs created after March 23, 2010. Federal officials also announced waivers for ACOs from the physician self-referral law, federal anti-kickback statute and the civil monetary penalties law.
Several measures of health information technology use, such as the percentage of primary-care providers who electronically prescribe medication or use clinical decision support, were omitted.
One measure of the use of electronic health records remained—but officials relaxed the criteria, which major physician and hospital trade groups praised. Draft rules required at least half of primary-care providers to earn the designation as Stage 1 meaningful users of health information technology by year two of the ACO. Final rules measure the percentage of primary-care doctors who qualify for an electronic health-record incentive payment.
CMS Administrator Dr. Donald Berwick touted the model as an opportunity to change how Medicare pays for medical care, which he again criticized as one culprit behind the nation's fragmented healthcare system.
Medical care that promotes communication among doctors and patients, education and prevention “hasn't always been the kind of care that Medicare has rewarded and encouraged,” Berwick said. “We still use a fee-for-service model largely to pay for pieces of care instead of for episodes of care and as a result that's what patients often get,” Berwick said. “They get pieces. They get fragments.”
The nation's healthcare delivery has stagnated even as biotechnology has delivered new and better treatments, Berwick said. “It's created miracles in its potential to help us to heal and to thrive. We know so much more now. But in the delivery of care, in the ways we make those miracles available to every single one of us, the changes have only been modest ones.”