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Supportive of intent of ACO proposed rule, ACP expresses concern

In a 10-page letter addressed to Donald Berwick, administrator of the Centers for Medicare and Medicaid Services, ACP today said:

The ACP strongly supports the intent of the proposed rule, and believes that an ACO model has the potential of supporting such important care delivery goals as enhancing quality, efficiency, integration, and patient-centeredness. The College is also pleased that the foundation of care under this payment model, as reflected in the proposed rule, is primary care. There is substantial research evidence derived from both domestic and international settings that a strong primary care foundation is the essence of an effective and efficient healthcare system.

We are concerned, though, that the current requirements proposed for acceptance as an ACO by Medicare under this program sets too high of a bar for participation by many internal medicine physicians, especially internal medicine specialists in primary and comprehensive care of adults who practice in smaller, independent physician practices. The required administrative, infrastructure, service delivery, and financial resources and the need to accept risk will effectively limit participation to those few large entities already organized under an ACO-like structure; that already have ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage). Even these entities have questioned the "business case" for adoption of the ACO model as outlined in the proposed rule. We do believe that the Center for Medicare and Medicaid Innovation's (CMMI) recent release of the Pioneer option, with its increased administrative flexibility and ability to earn a higher share of savings than allowed in the proposed rule, may effectively address this issue for the larger, already prepared players. We also are intrigued by the proposal from CMMI for an "advance payment" initiative for ACOs participating in the Medicare Shared Savings Program, which may be attractive to ACOs organized around smaller practices, and will be providing separate comments on this option. We believe there are a substantial number of physician practice collaborations of varying size, particularly those already providing primary care services that have achieved or are prepared to achieve recognition as qualified Patient-Centered Medical Homes, that would now or in the near future be interested in exploring the possibility of partnering with CMS within a shared saving payment structure; but the current requirements make such a consideration impractical. This is unfortunate. It is the hope of ACP that through suggested changes within the proposed rule, and/or through new initiatives through the CMMI, there will be an increased opportunity for a wider scope of physician practices to participate under the new payment model.

To address this shortcoming, the College recommends that CMS create a pathway for practices of varying sizes and level of practice transformation to participate in ACOs, including offering a "laddered" approach to participation, providing a true "up side" shared savings option where participating entities will be able to share in any saving compared to the established benchmark but will not be expected to share in any losses, and reducing the burdens on physicians of reporting on quality measures. ACP also supported the proposed rule's strong emphasis on primary care, but recommended a prospective patient attribution methodology based on the primary care physicians who provide the plurality of patient care (with changes to ensure that primary care physicians who see patients in the hospital or offer ancillary services are not excluded), and counting the contributions of internal medicine subspecialists who provide comprehensive primary care in rural and similar underserved healthcare areas in which there are not a sufficient number of primary care physicians.


Contact: David Kinsman
American College of Physicians

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