Basic Premise Of ACO Rule Remains Flawed, ACR Says

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imageSignificant changes to a proposed rule by the Centers for Medicare and Medicaid Services (CMS) that sets forth requirements and expectations for implementing the mandated Medicare Shared Savings program through Accountable Care Organizations (ACOs) are warranted, according to the American College of Radiology (ACR). In a June 3 letter written by ACR CEO Harvey L. Neiman, MD, FACR, and addressed to CMS Administrator Donald Berwick, MD, the ACR expresses multiple concerns regarding the assignment of beneficiaries, the tight linkage of quality measures to shared savings, the heavy emphasis on patient-centeredness, and other issues.

“The ACR is concerned that the basic premise of this proposed rule is flawed,” the letter says, noting that CMS “expects organizations to manage a population of patients that is unknown to them and beyond their control, making it extremely difficult to set up a successful model of integrated patient care” and that “the concept of tying the entire structure to the reporting of quality metrics with the goal of cutting costs while making patients the final arbiter” will not work. The ACR contends that shared savings seemingly cannot be realized by many groups that would like to participate in the ACO model.

“As evidenced by the Blue Cross and Blue Shield of Massachusetts (BCBS of MA) model quoted in the rule, a defined population is under a capitated fee-for-service agreement,” Neiman writes. “If the organization provides care within the cap, the savings realized are paid to that organization. Additionally, quality measures that are met will generate added savings. In this model, the two methods of achieving savings are not dependent upon each other. Conversely, in the ACO proposal, an organization would be required to participate in all 65 quality measures in addition to functioning within a budget in order to realize any savings. The return on investment for a contract such as this would be very questionable. One necessary remedy is for the patient satisfaction measures to be decoupled from the quality measures that show shared savings.”

On the beneficiaries front, the letter says, the ACR believes that inevitable patient attrition from ACOs renders the concept of establishing organizations “with a size anywhere near the minimum threshold of 5,000 beneficiaries, to say nothing of the economies of scale which would be lost in establishing an operation that small”, a risky one. Moreover, Neiman notes, the amount of investment required for such an endeavor, the level of risk involved, and a spate of stringent reporting requirements would make compliance difficult for small groups and the realization of any kind of shared services highly unlikely.

While the ACR is in favor of attributing patients to an ACO at the beginning of the process so that both the ACO and providers are aware of which patient’s care and costs are being tracked, it holds that the ability to characterize and attribute patients to a specific ACO will nonetheless be problematic without “clear guidance”. Its rationale: If a patient initially attributed to an ACO elects to leave that ACO for care, the latter should not be attributed to the ACO. “It is common for Medicare beneficiaries to live part of the year in one state and another part of the year in an entirely different part of the country,” but there remains the question of how these patients will be assigned, according to the letter.

Retrospective ACO attribution will pose challenge as well, the ACR alleges. “One of the major tenets of health care reform is eliminating fragmented care,” Neiman writes. “Therefore, we believe that CMS cannot design a system where patients choose fragmented care but make the ACOs accountable by misattribution. The rules of attribution should be made clear at the outset and remain consistent throughout the covered period.”

In terms of patient-centered care as it relates to diagnostic imaging, the ACR recommends that radiologists be assigned a pivotal role in assuring appropriate utilization of services within any given ACO. Using appropriateness criteria and other measures, Neiman points out in the letter, radiologists can substantially decrease inappropriate utilization, with cost savings to the ACO and decreased radiation dose to patients. Other recommendations stipulate that radiation dose management be one of the patient-centered quality criteria, as radiation dose management is complex, must be tailored to individual patients,