Perspective
Making Good on ACOs' Promise — The Final Rule for the Medicare Shared Savings Program
N Engl J Med 2011; 365:1753-1756November 10, 2011DOI: 10.1056/NEJMp1111671
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open through November 16, 2011
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During my career as a practicing pediatrician, my patients and I benefited from being part of a well-managed system of care, coordinated and financed to support seamlessness and patient-centeredness. We had an electronic health record — always available and up to the minute — which reminded me when a test or follow-up was due. For children with severe asthma, I worked as part of a team, with a home health nurse to teach skills and anticipate needs, an allergist instantly available as a coach, pharmacists to help plan care and detect errors, and advanced practice nurses to ensure 24/7 access. As a result, my patients stayed out of emergency rooms and hospital beds, remaining at home and in school, where they belonged. Function improved and costs fell.
The dedicated professionals in the U.S. health care system work to deliver the highest-quality health care they can. But as any health care provider will tell you, our system is full of roadblocks, red tape, and frustrations that keep them from practicing the type of medicine that most clinicians envisioned when they chose their noble field.
Physicians, nurses, and other health care professionals want the support required to work with engaged patients to make the clinical decisions most appropriate to their circumstances; to collaborate with colleagues to provide a safe, seamless experience; and to be paid for keeping people well. Instead, the status quo — with inadequate dissemination of usable clinical information, misaligned financial incentives, and in many cases, inertia — is rife with barriers to the coordinated care that patients want, providers want to give, and our unsustainable system so desperately needs.
To be sure, exactly this type of medicine is practiced every day in hundreds of places throughout the country. Innovative entrepreneurs and dedicated clinicians have found ways to break down barriers and redesign care to better help their patients and communities. But bringing the best of our system to every community in the country is the health care challenge of our time.
Eighteen months after President Barack Obama signed the Affordable Care Act, the Department of Health and Human Services (DHHS) has created a broad array of pathways for health care providers to begin — or in many cases, accelerate — their care-improvement journey in partnership with the Medicare and Medicaid programs and in synergy with the private sector. Today, the DHHS is taking its next major step by finalizing the rules for the establishment of accountable care organizations (ACOs) under the Medicare Shared Savings Program created by Section 3022 of the health care reform law.
ACOs are voluntary groups of physicians, hospitals, and other health care providers that are willing to assume responsibility for the care of a clearly defined population of Medicare beneficiaries attributed to them on the basis of patients' use of primary care services. If an ACO succeeds in both delivering high-quality care or improving care and reducing the cost of that care below what would otherwise have been expected, it will share in the savings it achieves for Medicare.
Under the ACO model, Medicare beneficiaries are still free to seek care from any Medicare provider they wish. Indeed, Medicare beneficiaries should find their care experience enhanced by a program that supports providers in engaging with their patients to deliver on the three-part aim: better care for individuals, better health for populations, and lower cost growth through improvements in care.
The DHHS proposed its initial set of guidelines for ACOs on March 31, 2011, and sought widespread comment on both the direction and the details of this important new program for Medicare. We at the Centers for Medicare and Medicaid Services (CMS) received more than 1200 formal comments from throughout the health care community, supplemented by feedback at dozens of informal listening sessions. The vast majority of the comments we received were supportive of the vision of the Shared Savings Program and optimistic about the potential for ACOs to be a force for change in our broken health care system. However, numerous suggestions were also offered for improvements to the proposed rule that would lead to a larger, more pluralistic set of ACO participants without compromising patient outcomes or choice. In particular, commenters asked CMS to reduce barriers to entry by streamlining governance and reporting burdens on potential ACOs; improve the potential financial return for ACOs willing to make the necessary, and often substantial, investments to improve care; and ensure beneficiary protections.
In response, CMS is making several significant changes in its final rule to strengthen the ACO program for providers and beneficiaries alike (see table
Proposed Rule vs. Final Rule for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program.). Major changes include providing better, and more timely, information to ACOs at the outset of the performance year through preliminary prospective alignment of beneficiaries (while retaining a retrospective reconciliation to ensure that ACOs are measured on the basis of the patients they actually care for during the year); retaining a strong monitoring and quality-measurement mechanism while streamlining the metrics to focus on what matters most, including reducing the total number of quality measures by about half; allowing start-up ACOs to choose a “savings only” track without financial risk during their initial contract period; sharing savings with successful ACOs on a “first dollar” basis when the ACO achieves meaningful savings for the Medicare program and improves care or provides high-quality care; and creating a pathway for full participation of federally qualified health centers and rural health clinics that provide a primary care safety net for Medicare beneficiaries in underserved areas.Taken together, these changes and numerous others create a more feasible and attractive on-ramp for a diverse set of providers and organizations to participate as ACOs. In addition, the Center for Medicare and Medicaid Innovation is announcing today an advanced payment initiative that will allow small physician practices and rural community hospitals that face particular challenges in forming ACOs to receive up-front access to needed capital.
For established organizations with a track record of providing robust coordinated care, the CMS innovation center is offering a pioneer ACO program designed to encourage and support the next wave of innovation from vanguard organizations that are positioned to help realize the full potential of the ACO model. And for organizations and clinicians not yet prepared to make the transition to ACOs, the DHHS is offering a menu of alternative options — including a comprehensive primary care program, bundled payments for care improvement, and a community-based transitional care program — that all seek to provide the incentives and supports necessary to move the mainstream of U.S. health care toward accountable care.
Whether provided through ACOs or an alternative innovation opportunity, coordinated care is meant to allow providers to break away from the tyranny of the 15-minute visit, instill a renewed sense of collegiality, and return to the type of medicine that patients and families want. For patients, coordinated care means more “quality time” with their physician and care team (a patient's advocate in an increasingly complex medical system) and more collaboration in leading a healthy life. And for Medicare, coordinated care represents the most promising path toward financial sustainability and away from alternatives that shift costs onto patients, providers, and private purchasers.
We believe that today's ACO rule is the next step in our shared commitment to a better, more lasting health care system. We look forward to being a trusted partner in our nation's journey toward patient-centered, coordinated care.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1111671) was published on October 20, 2011, at NEJM.org.
Source Information
Dr. Berwick is the administrator of the Centers for Medicare and Medicaid Services, Baltimore.
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- Comments (4)
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4 Reader's Comments
GEORGE MARGELIS, MD | Physician - GENERAL PRACTICE | Disclosure: NoneMAROUBRA AustraliaNovember 09, 2011International Collaboration on Coordinated Care Models
The ACO model is very similar in goals and aspirations as the Medicare Locals in Australia so I believe there are huge opportunities for international collaboration on how these new models can be delivered to a heterogeneous population. Reimbursement policy is a big driver for this innovation to occur, and allowing clinicians to experiment with how they deliver on the new models is important. The main issue then is how do we ensure we all learn from the experience and make it sustainable.
KOLALA SRIDAHR, MD | Physician - GASTROENTEROLOGY | Disclosure: NoneNORWICH CTOctober 26, 2011This is mere propaganda
ACOs, EHRs and yet other provisions of the affordable health care act will eventually destroy medical practice. Those doctors who can exit (perhaps like Dr. Berwick) will leave and every one else will provide the very affordable but generic medical care which will be government centered rather than patient centered. Good luck to all rural American citizens who cannot attract enough Physicians to build ACOs
RICHARD WEISS, MD | Physician - INTERNAL MEDICINE | Disclosure: NoneMARINA DEL REY CAOctober 20, 2011ACO. Who Pays for more Employees (nurses, PA, health coach....)?
Im in a three doctor practice with rent and labor higher every year, 20 patients per day, rounds in the hospital at least once daily, return calls to nurses in the hospital, families, patients, and consultants. We must oversee billing, receptioniists, and back-office personnel. We work 10 hour days, finish paper work and read 1-2 journals at home. Where is the time for our family?
No collective voice?
Medical Homes have subsidies (grants, government, AHRQ) that allow the personnel you describe. We do not know what the words ACO,community and bundling payments mean. Who is supposed to provide the daily change in our landscape? Our patients have chronic complex illnesses that are not generalizable to most studies as they do not qualify as patients in randomized trials. Medical school models did not train us to follow patients for years. We use a five hundred bed teaching hospital.
There is a widening gulf betweeen Academia and office practice doctors.
Patient-centered, coordinated care is possible knowing Single Patient Based
We can aim to achieve patient-centered, coordinated care, according to ACO, at the condition that physicians know what Single Patient Baesd Medicine means.