The long-awaited final rule for ACOs, published Thursday, contains just 33 quality measures, half of what an earlier proposal called for, divided into four domains: patient/caregiver experience; care coordination and patient safety; preventive health; and caring for at-risk populations. The idea is to "create a more feasible and attractive onramp for a diverse set of providers and organizations to participate as ACOs," Centers for Medicare and Medicaid Services (CMS) administrator Dr. Donald M. Berwick wrote in a New England Journal of Medicine commentary that accompanied the rule's release.
While not mandating the use of electronic health records (EHRs) and other forms of health IT for participation in the voluntary ACO initiative, the plan for what is to be known as the Medicare Shared Savings Program relies heavily on the ability for healthcare providers to collect and share data.
"ACOs, ACO participants, and ACO providers/suppliers are encouraged to develop a robust EHR infrastructure," the 696-page final rule states. Though ACOs will report only one of the 33 quality measures directly from an EHR--the percentage of primary care physicians who qualify for Meaningful Use incentive payments--that one will count twice what the other measures do in terms of assessing quality performance.
[As the first year of Meaningful Use winds down, get the latest on EHR Best Practices: Who's Winning And Why?]
Until more EHRs are in place, CMS will mostly rely on claims data, patient satisfaction surveys, and a CMS Web portal for measuring compliance. The agency did reserve the right to change its mechanisms in the future, however.
CMS also indicated that many of the more than 1,200 comments it received in response to a March 31 proposal highlighted the role of health information exchange (HIE) in care coordination, so the Medicare agency introduced some flexibility to the final rule.
"We agree that ACOs should coordinate care between all types of providers and across all services. We also agree that health information exchanges are of the utmost importance for both effective coordination of care activities and the success of the Shared Savings Program. We understand that there will be variable ability among ACOs to adopt the appropriate health information exchange technologies, but underscore the importance of robust health information exchange tools in effective care coordination," CMS said in the rule's lengthy preamble.
CMS thus decided to allow a two-stage start in the first year of an organization's participation in the three-year Shared Savings Program, acknowledging that few providers will have strong HIE infrastructure ready when the rules take effect Jan. 1. The agency wants prospective ACOs to "get the appropriate health information exchanges in place before they enter the program."
Starting in the second year of an ACO's participation, some Medicare reimbursement will switch from traditional fee-for-service to a pay-for-performance--or at least pay-for-reporting--model. The higher quality providers deliver, the greater their payments for shared savings, according to CMS. "This model of delivering care may not be right for everyone, but it provides new incentives for doctors, hospitals, and other healthcare providers to work together in new ways," U.S. Department of Health and Human Services secretary Kathleen Sebelius said in a statement.
The federal government expects to save as much as $940 million over four years through voluntary private-sector adoption of the voluntary program. The ACO rule also provides for advance payments to some rural providers and physician-owned practices to acquire IT or hire new staff.