ACOs, Ready to Roll?

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imageHHS issued its proposed rules for ACOs yesterday, offering guidance for hospitals, physicians, and other providers who intend to build one of these beasts, and thereby participate as early as 2012 in assuming responsibility for the care of a minimum of 5,000 patients. You thought your job was difficult before? This is health care reform’s special sauce, the call to action to health care providers to invent ways to bend that cost curve. HHS projects savings of $960 million over three years with this program. In projecting $800 million in bonus payments to successful ACOs over the next 3 years, participating in an ACO could be the health care provider’s best defense against declining reimbursement. But there is risk involved. The agency predicts that some ACOs will fail to meet program goals, thereby costing them $40 million.

Under the proposal, ACOs—described by HHS as teams of doctors, hospitals, and other health care providers and suppliers working together—would coordinate and improve care for patients with original Medicare (those who are not in Medicare Advantage private health plans). To share in savings, ACOs will have to meet quality standards in five key areas: patient/caregiver care experiences; care coordination; patient safety; preventive health; and at-risk population/frail elderly health. The proposed rules include protections to ensure patients do not have their care choices limited by an ACO, as well as provide guidance to providers concerned about running afoul of fraud and abuse, antitrust, and tax laws.

Both the 427-page proposed rule and the 25-page joint CMS/OIG guidance on fraud and abuse, antitrust, and tax issues can be found here. Check out Kaiser Health’s post-release coverage, and visit the government’s ACO information page. This is a proposed rule and comments are due in June.

The joint statement by the OIG and CMS, signed by Donald M. Berwick, CMS administrator, asks specifically for comment on whether CMS should create waivers of the application of the Self Referral Laws and the federal anti-kickback statute to specified financial arrangements involving ACOs.

Radiologists and other specialists understandably are feeling left out of the ACO party. But don’t fall asleep at the wheel: Clearly, as this program rolls out, there could be long-lasting ramifications for the specialty.