The American College of Physicians (ACP) has raised concerns regarding the recommendation that at least 50% of participating primary care participants within an Accountable Care Organization (ACO) be meaningful users of health information technology by the second year of the contract. This requirement, along with several others that have been outlined in the proposed rules for ACOs, has been cited by the ACP as measures that will limit the participation of many physicians and could hurt the development of ACOs moving forward.
"The college supports the importance of Electronic Health Record (EHR) adoption, but believes that this 50% requirement may be too high a goal--particularly for small and intermediate size practice collaborations considering participating within the ACO program. This concern is further magnified by the fact that the more difficult Stage 2 criteria for Meaningful Use will be in effect in 2013," Don Hatton, ACP's chair, Medical Practice and Quality Committee, said in a ten page letter dated June 2 to Donald Berwick, administrator for the Centers for Medicare & Medicaid Services (CMS).
The ACP recommends that the meaningful use requirement be reduced and made variable "based upon the degree of risk and gain potential accepted by the entity. Requirements at each option level can be ramped-up over time."
The meaningful use requirement--as well as other criteria that must be met to participate in an ACO--"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," Hatton said.
The letter, which was sent in response to CMS' request for comments on the proposed rules for ACOs that was issued earlier this year, further notes that the challenge to meet administrative, infrastructure, service delivery, and financial resources and the need to accept risk will foster an ACO model that is more conducive to attracting large entities already organized under an ACO-like structure. These entities have "ready access to capital, substantial infrastructure development, and experience operating under an integrative service/payment model (e.g. Medicare Advantage)," the letter said.
To level the playing field, the college recommends that CMS create a pathway for practices of varying sizes to participate in ACOs, including offering a "laddered" approach to participation, providing a true "upside" shared savings option where participating entities will be able to share in any savings compared to the established benchmark but will not be expected to share in any losses. The college also recommends reducing the burden on physicians of reporting on quality measures.
On the issue of quality measures, Hatton said that under the proposed rule, participating entities are required to report 65 total quality measures covering five key areas: patient experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. With only 11 of the quality measures being claims based on data originating from CMS, the remaining measure data sources will comprise either survey data or data being reported through the Group Practice Reporting Option (GPRO) methodology. Collecting and sorting this data can be onerous for participating entities and has significant implications for the health IT infrastructure that will be required to support this data collection.
"It is essential that CMS set up systems to lessen this reporting burden--particularly by developing workable interfaces so that the necessary data can be easily abstracted from Electronic Health Records, and entities can be assisted to reasonably obtain the necessary survey data," Hatton wrote. "The College further recommends that CMS include the use of data reporting through registries--this is particularly important to specialty practices participating within an ACO that already participate in substantial data reporting through registries developed by their specialty societies."
ACP wants to see physicians at small and midsize practices encouraged to engage in ACOs as a way to improve quality, efficiency, and healthcare coordination, as well as focus on a patient-centered model. But for that to happen, significant assistance is needed.
According to Hatton, at a minimum ACOs require:
-- The availability of an upside only shared savings option;
-- The availability of access to developmental capital as no-cost loans, competitive developmental grants, and advanced up-front payments of expected savings;
-- Technical assistance in establishing these collaborative potential ACO entities and in achieving the necessary administrative, operational, and service delivery requirements to successfully function under this delivery and payment model.
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