“ACOs are having difficulty coordinating care because they don't know who their patients are and, if patients see providers outside of your network, it's hard to control cost and quality,” said Chet Speed, vice president of public policy with the American Medical Group Association. “The problem with ACOs is that you have care-management requirements overlayed on a very imperfect fee-for-service system.”
The BCP also will risk-adjust payments for patients who require the most complex care, another incentive for providers to participate in the program, said Dr. William Bornstein, CMO and chief quality officer for Atlanta's Emory Healthcare. This will encourage some systems and physician practices to actually recruit Medicare patients with multiple chronic conditions by specializing in caring for that particular patient population and building the necessary infrastructure.
ACOs, by contrast, get a mix of very sick and relatively healthy patients. Those that lost money or broke even in the program may have lacked the resources to focus on the very sick, Bornstein said.
The fact that the program provides for shared savings—anything under the cap stays with the provider—should focus hospitals and physicians like a laser beam on reducing waste and providing targeted services aimed at keeping people out of the hospital. Dr. A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design, called Wyden's bill the first legislation to include “clinically nuanced” principles that acknowledge a healthcare service has different value depending on who's receiving it, who's delivering it and where.
Payers such as Cigna Corp. also have stood up to support the Better Care, Lower Cost Act. “We know that better management of chronic illness is essential to helping Medicare customers avoid complications and remain independent and active,” said Graham Harrison, spokeswoman for Nashville-based Cigna-HealthSpring.
But there are still numerous design pitfalls that could undermine the program. Setting appropriate global payments “is critical to ensuring providers have the resources to provide the range of care envisioned in the bill,” said Dr. Lee Sacks, executive vice president and CMO for Downers Grove, Ill.-based Advocate Health Care, who is generally supportive. “Sens. Wyden and Isakson are proposing the next generation of an alternative payment model—taking the strengths of accountable care and care coordination and adding the flexibility and market-based provisions of the Medicare Advantage program.”
Many inside-the-Beltway lobbyists remain far from bullish on the bill's prospects. AARP, the nation's largest and most powerful senior citizen lobby, supports the opt-in feature of the legislation and lauds its incentives for improving health and holding down costs. But “I think it's very hard in the current environment to pass a healthcare bill given the contentious issue healthcare has been in this Congress,” said David Certner, legislative counsel and legislative policy director for the group.
It might fare better if it is attached to the SGR fix legislation, which is certain to consume Congress in the next few months. While conventional wisdom says that's unlikely, much will depend on how the Congressional Budget Office scores the legislation. Wyden claimed it has the potential to save $25 billion a year—more than enough to fund the doc-fix.
If the Hill's official bean-counting agency confirms his back-of-the-envelop estimate, the BCP could gain traction. “SGR is the engine driving the train, and how that turns out may determine how any other healthcare bills get dealt with,” said Julius Hobson, a former American Medical Association lobbyist now at the Polsinelli law firm.
Follow Andis Robeznieks on Twitter: @MHARobeznieks