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Oncology Times:
doi: 10.1097/01.COT.0000394481.09588.7b
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CMS's Draft ACO Regulations Expected Any Day Now

Butcher, Lola

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The Centers for Medicare & Medicaid Services is expected to release its draft regulations for accountable care organizations (ACOs) very soon—probably in late January or early February.

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The regulations are important to oncologists because the ACO model is emerging as one of the primary payment reforms for physicians and other health care providers. Among other things, the regulations will determine how ACOs will work, which can affect how oncologists make money and how much control they have over their practices.

Members of the oncology community fall into two categories: those who are enthusiastic about the ACO model and those who are worried about it.

“It's difficult at this point to know if it's going to be an opportunity or a threat, said Matthew Farber, Director of Provider Economics and Public Policy for the Association of Community Cancer Centers. There are definitely a number of concerns that many of our members have. But some of our hospital-based practices and even some large multispecialty practices see it as an opportunity.”

In general, large multispecialty practices and hospital-based practices are better positioned to participate in an ACO because they can afford—or already have—the information technology needed to coordinate all facets of patient care, which is key to improving health status and reducing costs.

Equally important, physicians or they multispecialty practices or hospital-based practices are already connected to other health care providers, which facilitates care coordination.

But most physicians still operate in small practices or single-specialty practices, so there will be strong opposition if CMS proposes ACO regulations that appear to shut them out of the game.

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What It Means to Oncologists

In oncology, the most vocal proponent of the ACO model is US Oncology. Pointing to a 2010 study that found that cancer care costs can be dramatically reduced without impairing patient outcomes (Journal of Oncology Practice 2010;6:12-18; 3/10/10 OT), Matt Brow, Vice President for Corporate Communications, Government Relations and Public Policy for US Oncology, said he believes that the shared savings concept could benefit oncologists because they can potentially bring huge savings to the Medicare program.

That means that oncologists participating in an ACO would share in that huge savings.

Indeed, US Oncology is advocating for oncology-only ACOs, in which oncologists serve as their patients' primary care physicians during the course of their cancer treatment and manage the care provided by hospitals and others.

The regulations that CMS is now writing will determine whether that is possible.

“Any actions that CMS might take in structuring the Medicare Shared Savings Program (MSSP) that would make it more difficult for oncologists to participate would be a significant lost opportunity for them”, Mr. Brow said.

The draft regulations were originally expected in December, but that deadline was scuttled after CMS issued a “request for information”, in which it asked interested parties to offer their thoughts on a few specific points. The deadline for submitting comments was Dec. 3.

The responses submitted by the American Society of Clinical Oncology and other health care organizations highlight some of the issues that oncologists should be watching:

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Issues Relevant to Ruraland Small Practices

Required number of patients served. The health reform law that created the MSSP specifies that ACOs must serve at least 5,000 Medicare beneficiaries. In its comments, ACCC said that both independent and hospital-based oncology practices in rural areas worry that they might not have enough patients—or other health care providers nearby—to form an ACO on their own.

Start-up investment. Participation in an ACO will require oncologists to use health care information technology to coordinate care with hospitals, other physicians, and other health care providers and to track patient outcomes. Additionally, oncologists will incur legal expenses because an ACO must be set up to legally allow receipt and distribution of “shared savings” payouts from Medicare.

“Our members are reluctant to incur these costs, disrupt their practices, and, most important, change their patients' sites of care and providers in order to participate in the Shared Savings Program or other tests of payment models with uncertain outcomes”, ACCC President Al B. Benson III, MD, said in a letter to CMS.

“These providers are concerned that they will be able to participate only if they cease to be independent entities and are acquired or employed by larger hospitals.”

ACCC recommends that CMS develop incentive payments for physicians to form ACOs. It also recommends that the administrative costs associated with participating in the MSSP be considered when calculating payments to participating physicians. Additionally, the organization wants CMS to establish standards that ensure patients have access to oncologists in their communities.

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What Quality Measures Will Be Used?

To qualify for a “shared savings” payout, an ACO must meet a quality performance standard, so CMS must decide what that standard is.

The ACP told CMS that, as much as possible, only quality measures approved by the National Quality Forum (NQF) or another multi-stakeholder consensus-based group should be used. Furthermore, the measures should be aligned with the performance measures currently being used in the Physician Quality Reporting System (formerly known as Physician Quality Reporting Initiative) and CMS's “meaningful use initiative” for electronic health records.

The American Hospital Association (AHA) asked CMS to use measures endorsed by NQF that comply with and that will also satisfy the “triple aim” of better care, healthy communities, and more affordable care. “Focusing on a small core measure set is the right approach for early phases of ACOs,” the AHA said in its comments.

Not so fast, ASCO says. ASCO CEO Allen S. Lichter, MD, said that CMS should not rely on “so-called quality measurement systems” that oversimplify medical care.

“At least in the case of oncology, CMS should not promote or encourage the use of quality programs that minimize the number of quality measures, rely solely or primarily on administrative data or fail to keep pace with rapidly evolving clinical and quality evidence,” he said.

ASCO wants CMS to adopt its Quality Oncology Practice Initiative (QOPI) measures to serve as the performance measurement approach for cancer care provided by ACOs. About 700 practices are currently participating in QOPI, which collects data on more than 80 performance measures and 17 safety standards for cancer care.

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Provision of Primary Care Services

The health reform law that created MSSP says that every ACO must include primary care physicians. US Oncology, which intends to create its own ACO, believes the law should allow an oncologist, nephrologist, or other physician who treats a patient over the course of an intensive illness to be considered a primary care physician.

“Primary care physicians do have to be part of an ACO, but not exactly in the way most of us traditionally think about primary care physicians,” Mr. Brow said.

ASCO salutes that perspective, and in its comments to CMS, noted that oncologists are often in the best position to manage comorbidities and other primary care services for patients who are being treated for cancer and cancer survivors as well.

“This is due to the fact that the underlying cancer and/or the therapies used to treat the cancer may have important impacts on the patient's primary care needs,” Dr. Lichter wrote.

The American College of Physicians, however, takes another view. Its letter to CMS acknowledged that non-primary care physician practices often provide “principal” care to patients that is usually coordinated and of high quality, but that CMS should ensure that ACOs include primary care physician practices.

Just to be clear what it means, ACP said that those primary care practices should be led by physicians trained in family medicine or one of five other primary care specialties. Not surprisingly, oncology was not listed.

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How Patients Are Assigned to an ACO

The quality of care provided by an ACO will be measured and the total costs calculated at the end of each performance period. Thus, the process of “attributing” patients to an ACO is important; if, for example, a patient is treated by an allergist who is in one ACO and a cardiologist in another ACO during the same performance period, which ACO is then held accountable for the cost and quality of that patient's care?

The ACP believes that ACO participation should be voluntary, meaning that patients choose an ACO for themselves.

“This engages the patient, strengthens the doctor-patient relationship, and facilitates efforts by all parties toward improved care,” ACP President Fred Ralston Jr., MD, said in his letter to CMS.

But very few patients would choose an oncologist-led ACO because most patients do not know they are going to need cancer care in the year ahead. Thus, US Oncology told CMS that patients should be assigned retroactively to an ACO. That is, at the end of a performance period, CMS should assign a patient to the ACO that provided the majority of evaluation and management services during the performance period.

In that approach, physicians participating in an ACO would not know which patients they will be held accountable for until the end of the performance period. Mr. Brow points out that would provide an incentive to provide an ACO-level of care for all patients.

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What is an ACO?

The basic concept of an accountable care organization (ACO) is that physicians and other health care providers can improve their patients' health status if the health care payment system incentivizes them to proactively manage patient care and avoid duplicative or unnecessary tests and procedures.

An ACO is a group of physicians and possibly other health care providers who jointly agree to be accountable for all the health care services for a defined patient population that includes at least 5,000 Medicare beneficiaries.

Beginning in 2012, CMS will be authorized to contract with ACOs through the Medicare Shared Savings Program (MSSP.) The term shared savings means that those providers who reduce Medicare's costs get to share those savings with Medicare.

Physicians will continue to be paid on a fee-for-service basis, but those who participate in an ACO will be eligible for shared savings payments if they meet quality standards and keep costs below a predetermined benchmark. ACO contracts will be at least three years.

Participation in an ACO will be voluntary. The MSSP is not a pilot or demonstration; it is a permanent program.

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More ACO information in Lola's OT blog!

Lola Butcher continues to follow the ins and outs of accountable care organizations for oncologists on her OT “Practice Matters” blog. Access it via the box on the oncologytimes.com home page, or click on “Blogs” to see the full network of OT blogs.

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© 2011 by Lippincott Williams & Wilkins, Inc.

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