The CMS is expected to issue final regulations soon that could significantly affect whether hospitals and doctors remain willing to participate in Medicare's accountable care program.
The Medicare Shared Savings Program for accountable care organizations provides incentives for hospitals and doctors to manage the medical cost and quality for a patient group. The new regulations could change the size of the incentives, how Medicare calculates ACO savings and which patients the hospitals and doctors are responsible for.
CMS officials and healthcare executives have argued over these critical elements since before the 2012 launch of Medicare accountable care. There are now more than 400 ACOs. HHS said in January it would push for many more.
A draft version of the regulations released last December included compromises designed to retain ACOs and entice more hospitals and doctors to participate.
Under the proposed rule, ACOs could stay in the program longer before they're required to take downside risk—meaning they would have to return money to government if costs exceed benchmarks. Those that choose to avoid risk, however, cannot keep as much of the savings they produce. The option to avoid risk may prevent smaller and less-prepared ACOs from leaving the program.
ACOs that agree to downside risk could take more (up to 75%) under a new option. Those ACOs also would find out which patients they must manage at the start of the year, rather than at the end of the year.
The CMS solicited ideas for how to calculate savings and adjust the calculation over time to reflect prior savings.
The wait for a final rule has left ACOs in suspense. “I think they're all waiting they're just as uncertain now as they were six months ago as to whether they will stay” said Clif Gaus, CEO of the National Association of ACOs. “A whole lot is riding on the final rule and whether or not the ACO has a better chance of achieving savings and improving care."
Among the details that will sway ACOs are those that affect financial performance, he said. ACOs should have a choice of whether they identify their patients at the start or end of the year. “There's pros and cons to both,” he said. “Let's let the ACO decide which is better for them.”
Gaus also said ACOs want the rules to calculate savings against regional Medicare spending rather than national trends, as is the case now. They also hope to see Medicare exclude prior savings from the baseline the government uses to calculate savings.
Possible waivers to Medicare rules for nursing home service would also be welcome, Gaus said. Patients must be admitted to the hospital for at least three days before Medicare's hospital benefits, known as Part A, will cover the cost of nursing home care. The CMS should waive this rule, he said.