New Ideas, Familiar Concerns

There I was, minding my own business, not bothering a soul, when suddenly my inbox was bombarded with e-mails regarding the latest iteration of “let’s fix the system.” A “notice of proposed rulemaking” for the Shared Savings Program appeared in the April 7, 2011, issue of the Federal Register,¹ and it seemed every faction of the health care and business fields had either a workshop or a publication about it on their docket.

Through section 3022 of the Affordable Care Act, a new section (1899) was added to the Social Security Act, establishing the Shared Savings Program (known as “Medicare Shared Savings Regulations”).² Under the new regulations, Medicare is given the authorization to contract with “accountable care organizations” (ACOs).

In my opinion, this is a rerun of the “tried and true” (but didn’t really work so well) performance-based measures. However, with the knowledge that all predictors indicate Medicare will be bankrupt by 2025, something that—at least in some fashion—may result in cost savings has to be tried again.

As I alluded to in my previous column, the US health care system is ripe for improvement, and the opportunities to make the system better for all of us seem boundless. While I wonder whether this “new” approach to improving care and lowering costs might meet the same demise as the previous attempts, I am intrigued by the components of this version of the shared approach to managing the bottom line. But more than that, I was initially pleased to see mention of “other care providers” as integral to this program.

In my desire to get myself back up to speed with the ACO concept, I did some research. I must share with you that, not surprisingly, there seems to be a bit of uncertainty as to the exact definition of an ACO. In simple terms, it is a network of doctors and hospitals who share the responsibility of providing high-quality care to patients.³ It is a modification, if you will, of the old “capitated group” concept that was neither widely received nor successful because of restrictions on provider choice and incentives to deny care.⁴ The difference is the payer focus: namely, Medicare. The sameness is the phrase “network of doctors.”

In the past, despite resistance to “integrated systems,” patients and providers (really physicians, but I choose neutral language) tended to stay within the same network for care. This suggests that organized systems may be preferable and also reduce unnecessary costs and use of resources.⁵ I would submit, anecdotally, that a significant component of the reduction in costs and use of resources is a function of the health care provided by NPs and PAs.

Unfortunately, without the hard facts to support this, we are again in jeopardy of being at the mercy of however individual ACOs are organized. In their report, Devers and Berenson⁵ note a definition of the ACO as “a local entity and a related set of providers, including at least primary care physicians….” To me, this is a warning that we might already be at the stage where which providers must be included—or rather, may be excluded—has been established. 

Over the past few years, the ACO concept has emerged as a means to encourage integration of systems and steer clear of the perceived problems of past efforts. And here is where my activist self re-emerged. I am concerned that the model is still physician driven, even though the statute specifies “other professionals” as eligible to be an ACO.⁶ Without the stipulation (or at least a “such as”) to include NPs and PAs, the opportunity to leave us out of the equation exists—again. We are the very providers who have long been “invisible,” yet we are more likely to spend that extra time with the population who is older than 65. 

I am not suggesting the die is cast, as others maintain that the issue of which providers must be included in the ACOs remains unclear. But it is obvious to me that we must advocate to be included in these organizations. The systems that are identified as possible candidates for ACO status have a history of reducing the number of NP and PA providers, often replacing them with physicians. We must be vigilant in demonstrating that we are the ones with the history of providing cost-effective, resource-sparing, and high-quality care to the populations we serve. 

It is apparent from the discussion regarding health care reform initiatives that collaboration among all health care providers must occur in order for us to move away from the dysfunctional fee-for-service system currently in place. There is also the distinct possibility that some health care organizations will resist a clinical redesign that includes value-based purchasing and incentive-based reimbursement. 

Because the ACO idea is new to the Medicare scene, it is expected to evolve over time. Given that the early language in the model is still somewhat physician specific, it is incumbent upon all health care professionals to stay involved in its progress to ensure there are no barriers to our being part of these systems. My eyes have been opened, and I will be watching as the Medicare Shared Savings Program for ACOs takes effect in 2012.

Send your thoughts on ACOs to NPEditor@qhc.com.

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Shared Savings Program: Accountable Care Organizations (76 FR 19528). federalregister.gov/a/2011-7880. Accessed May 16, 2011.

2. US Department of Health and Human Services. Summary of proposed rule provision for accountable care organizations under the Medicare Shared Savings Program (April 2011). www.cms.gov/MLNProducts/downloads/ACO_NPRM_Summary_Factsheet_ICN906224.pdf. Accessed May 16, 2011.

3. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief: Accountable care organizations (July 27, 2010). www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20. Accessed May 16, 2011.

4. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicare Innovation should test accountable care organizations. Health Affairs. 2010;29(7):1293-1298.

5. Devers K, Berenson R. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Robert Wood Johnson Foundation/Urban Institute Policy Brief; October 2009. www.rwjf.org/qualityequality/product.jsp?id=50609. Accessed May 16, 2011.

6. Centers for Medicare & Medicaid Services Office of Legislation. Medicare Accountable Care Organizations Shared Savings Program: New Section 1899 of Title XVIII Preliminary Questions and Answers (May 2010). www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed May 1, 2011.

There I was, minding my own business, not bothering a soul, when suddenly my inbox was bombarded with e-mails regarding the latest iteration of “let’s fix the system.” A “notice of proposed rulemaking” for the Shared Savings Program appeared in the April 7, 2011, issue of the Federal Register,¹ and it seemed every faction of the health care and business fields had either a workshop or a publication about it on their docket.

Through section 3022 of the Affordable Care Act, a new section (1899) was added to the Social Security Act, establishing the Shared Savings Program (known as “Medicare Shared Savings Regulations”).² Under the new regulations, Medicare is given the authorization to contract with “accountable care organizations” (ACOs).

In my opinion, this is a rerun of the “tried and true” (but didn’t really work so well) performance-based measures. However, with the knowledge that all predictors indicate Medicare will be bankrupt by 2025, something that—at least in some fashion—may result in cost savings has to be tried again.

As I alluded to in my previous column, the US health care system is ripe for improvement, and the opportunities to make the system better for all of us seem boundless. While I wonder whether this “new” approach to improving care and lowering costs might meet the same demise as the previous attempts, I am intrigued by the components of this version of the shared approach to managing the bottom line. But more than that, I was initially pleased to see mention of “other care providers” as integral to this program.

In my desire to get myself back up to speed with the ACO concept, I did some research. I must share with you that, not surprisingly, there seems to be a bit of uncertainty as to the exact definition of an ACO. In simple terms, it is a network of doctors and hospitals who share the responsibility of providing high-quality care to patients.³ It is a modification, if you will, of the old “capitated group” concept that was neither widely received nor successful because of restrictions on provider choice and incentives to deny care.⁴ The difference is the payer focus: namely, Medicare. The sameness is the phrase “network of doctors.”

In the past, despite resistance to “integrated systems,” patients and providers (really physicians, but I choose neutral language) tended to stay within the same network for care. This suggests that organized systems may be preferable and also reduce unnecessary costs and use of resources.⁵ I would submit, anecdotally, that a significant component of the reduction in costs and use of resources is a function of the health care provided by NPs and PAs.

Unfortunately, without the hard facts to support this, we are again in jeopardy of being at the mercy of however individual ACOs are organized. In their report, Devers and Berenson⁵ note a definition of the ACO as “a local entity and a related set of providers, including at least primary care physicians….” To me, this is a warning that we might already be at the stage where which providers must be included—or rather, may be excluded—has been established. 

Over the past few years, the ACO concept has emerged as a means to encourage integration of systems and steer clear of the perceived problems of past efforts. And here is where my activist self re-emerged. I am concerned that the model is still physician driven, even though the statute specifies “other professionals” as eligible to be an ACO.⁶ Without the stipulation (or at least a “such as”) to include NPs and PAs, the opportunity to leave us out of the equation exists—again. We are the very providers who have long been “invisible,” yet we are more likely to spend that extra time with the population who is older than 65. 

I am not suggesting the die is cast, as others maintain that the issue of which providers must be included in the ACOs remains unclear. But it is obvious to me that we must advocate to be included in these organizations. The systems that are identified as possible candidates for ACO status have a history of reducing the number of NP and PA providers, often replacing them with physicians. We must be vigilant in demonstrating that we are the ones with the history of providing cost-effective, resource-sparing, and high-quality care to the populations we serve. 

It is apparent from the discussion regarding health care reform initiatives that collaboration among all health care providers must occur in order for us to move away from the dysfunctional fee-for-service system currently in place. There is also the distinct possibility that some health care organizations will resist a clinical redesign that includes value-based purchasing and incentive-based reimbursement. 

Because the ACO idea is new to the Medicare scene, it is expected to evolve over time. Given that the early language in the model is still somewhat physician specific, it is incumbent upon all health care professionals to stay involved in its progress to ensure there are no barriers to our being part of these systems. My eyes have been opened, and I will be watching as the Medicare Shared Savings Program for ACOs takes effect in 2012.

Send your thoughts on ACOs to NPEditor@qhc.com.

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Shared Savings Program: Accountable Care Organizations (76 FR 19528). federalregister.gov/a/2011-7880. Accessed May 16, 2011.

2. US Department of Health and Human Services. Summary of proposed rule provision for accountable care organizations under the Medicare Shared Savings Program (April 2011). www.cms.gov/MLNProducts/downloads/ACO_NPRM_Summary_Factsheet_ICN906224.pdf. Accessed May 16, 2011.

3. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief: Accountable care organizations (July 27, 2010). www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20. Accessed May 16, 2011.

4. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicare Innovation should test accountable care organizations. Health Affairs. 2010;29(7):1293-1298.

5. Devers K, Berenson R. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Robert Wood Johnson Foundation/Urban Institute Policy Brief; October 2009. www.rwjf.org/qualityequality/product.jsp?id=50609. Accessed May 16, 2011.

6. Centers for Medicare & Medicaid Services Office of Legislation. Medicare Accountable Care Organizations Shared Savings Program: New Section 1899 of Title XVIII Preliminary Questions and Answers (May 2010). www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed May 1, 2011.

There I was, minding my own business, not bothering a soul, when suddenly my inbox was bombarded with e-mails regarding the latest iteration of “let’s fix the system.” A “notice of proposed rulemaking” for the Shared Savings Program appeared in the April 7, 2011, issue of the Federal Register,¹ and it seemed every faction of the health care and business fields had either a workshop or a publication about it on their docket.

Through section 3022 of the Affordable Care Act, a new section (1899) was added to the Social Security Act, establishing the Shared Savings Program (known as “Medicare Shared Savings Regulations”).² Under the new regulations, Medicare is given the authorization to contract with “accountable care organizations” (ACOs).

In my opinion, this is a rerun of the “tried and true” (but didn’t really work so well) performance-based measures. However, with the knowledge that all predictors indicate Medicare will be bankrupt by 2025, something that—at least in some fashion—may result in cost savings has to be tried again.

As I alluded to in my previous column, the US health care system is ripe for improvement, and the opportunities to make the system better for all of us seem boundless. While I wonder whether this “new” approach to improving care and lowering costs might meet the same demise as the previous attempts, I am intrigued by the components of this version of the shared approach to managing the bottom line. But more than that, I was initially pleased to see mention of “other care providers” as integral to this program.

In my desire to get myself back up to speed with the ACO concept, I did some research. I must share with you that, not surprisingly, there seems to be a bit of uncertainty as to the exact definition of an ACO. In simple terms, it is a network of doctors and hospitals who share the responsibility of providing high-quality care to patients.³ It is a modification, if you will, of the old “capitated group” concept that was neither widely received nor successful because of restrictions on provider choice and incentives to deny care.⁴ The difference is the payer focus: namely, Medicare. The sameness is the phrase “network of doctors.”

In the past, despite resistance to “integrated systems,” patients and providers (really physicians, but I choose neutral language) tended to stay within the same network for care. This suggests that organized systems may be preferable and also reduce unnecessary costs and use of resources.⁵ I would submit, anecdotally, that a significant component of the reduction in costs and use of resources is a function of the health care provided by NPs and PAs.

Unfortunately, without the hard facts to support this, we are again in jeopardy of being at the mercy of however individual ACOs are organized. In their report, Devers and Berenson⁵ note a definition of the ACO as “a local entity and a related set of providers, including at least primary care physicians….” To me, this is a warning that we might already be at the stage where which providers must be included—or rather, may be excluded—has been established. 

Over the past few years, the ACO concept has emerged as a means to encourage integration of systems and steer clear of the perceived problems of past efforts. And here is where my activist self re-emerged. I am concerned that the model is still physician driven, even though the statute specifies “other professionals” as eligible to be an ACO.⁶ Without the stipulation (or at least a “such as”) to include NPs and PAs, the opportunity to leave us out of the equation exists—again. We are the very providers who have long been “invisible,” yet we are more likely to spend that extra time with the population who is older than 65. 

I am not suggesting the die is cast, as others maintain that the issue of which providers must be included in the ACOs remains unclear. But it is obvious to me that we must advocate to be included in these organizations. The systems that are identified as possible candidates for ACO status have a history of reducing the number of NP and PA providers, often replacing them with physicians. We must be vigilant in demonstrating that we are the ones with the history of providing cost-effective, resource-sparing, and high-quality care to the populations we serve. 

It is apparent from the discussion regarding health care reform initiatives that collaboration among all health care providers must occur in order for us to move away from the dysfunctional fee-for-service system currently in place. There is also the distinct possibility that some health care organizations will resist a clinical redesign that includes value-based purchasing and incentive-based reimbursement. 

Because the ACO idea is new to the Medicare scene, it is expected to evolve over time. Given that the early language in the model is still somewhat physician specific, it is incumbent upon all health care professionals to stay involved in its progress to ensure there are no barriers to our being part of these systems. My eyes have been opened, and I will be watching as the Medicare Shared Savings Program for ACOs takes effect in 2012.

Send your thoughts on ACOs to NPEditor@qhc.com.

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Shared Savings Program: Accountable Care Organizations (76 FR 19528). federalregister.gov/a/2011-7880. Accessed May 16, 2011.

2. US Department of Health and Human Services. Summary of proposed rule provision for accountable care organizations under the Medicare Shared Savings Program (April 2011). www.cms.gov/MLNProducts/downloads/ACO_NPRM_Summary_Factsheet_ICN906224.pdf. Accessed May 16, 2011.

3. Health Affairs/Robert Wood Johnson Foundation. Health Policy Brief: Accountable care organizations (July 27, 2010). www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20. Accessed May 16, 2011.

4. Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicare Innovation should test accountable care organizations. Health Affairs. 2010;29(7):1293-1298.

5. Devers K, Berenson R. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Robert Wood Johnson Foundation/Urban Institute Policy Brief; October 2009. www.rwjf.org/qualityequality/product.jsp?id=50609. Accessed May 16, 2011.

6. Centers for Medicare & Medicaid Services Office of Legislation. Medicare Accountable Care Organizations Shared Savings Program: New Section 1899 of Title XVIII Preliminary Questions and Answers (May 2010). www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed May 1, 2011.