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Final ACO rule released; requirements softened

Photo by Grant HuangYou’ll face less risk and fewer administrative hassles if you choose to participate in an accountable care organization (ACO), thanks to changes made in the final ACO rule, released today in the Federal Register. CMS took pains to review feedback from physician advocacy groups and believes the final rule takes many of their biggest concerns into account, top agency officials said during a conference call with reporters.

“We feel the rule is very responsive to the comments and concerns that came to us,” said Jonathan Blum, CMS deputy administrator and director. “We feel we’ve struck a better balance between building a stronger business case to providers and at the same time not taking away a patient protection framework.”

It’s super early for any definitive analysis of the final rule, but so far it appears to soften requirements in the proposed rule, especially those that were most burdensome to practices, says George Roman, senior director of health policy for the American Medical Group Association (AMGA). “The proposed framework didn’t produce anything among our members but disappointment and consternation,” he says. “Now my preliminary sense is that CMS has listened and has made some concessions.”

A few big features of the final rule stand out as positive changes from the proposed rule, Roman says.

  • Downside risk no longer mandatory. There are still two ACO “tracks” or models that run over three years, but now the first track involves no shared downside risk. In other words, practices participating in the first track would share any savings generated, but would not owe any money if ACO care costs wind up higher than traditional fee-for-service costs.
  • Quality measures cut in half. One big complaint about the proposed rule was that it required participating practices to track and report 65 quality measures to CMS. That number has been slashed to 33 in the final rule.
  • Upfront payments to help with capital costs. CMS will provide upfront payments to ACOs to help defray the capital costs of forming an ACO, with the expectation that the payments be recouped via savings over time. There was no such assistance in the proposed rule.
  • No more EHR requirement. The proposed rule required that 50% of primary care physicians in an ACO achieve meaningful use with electronic health records (EHRs); this has been dropped in the final rule.

Of course, these observations are based just on a “very limited and select reading of the rule so far,” Roman warns. “I’m still trying to get through all 696 or 697 pages, I believe.”

Major stakeholder groups such as the AMA also sounded optimistic, if still conservative. “After preliminary review, the AMA believes this final rule includes a number of positive changes,” said AMA President Peter W. Carmel, MD, in a prepared statement. But, effectively in the same breath, Dr. Carmel warned that the ACO final rule “requires a full, in-depth review to ensure it maximizes those potential benefits for Medicare patients and physicians.”

TIP: CMS will offer free "learning sessions" to educate anyone interested in ACOs at its headquarters in Baltimore, Md. The next session takes place from Nov. 17-18. You can get more information from the official ACO website here.

Stay tuned for comprehensive analysis and guidance in the next issue of Part B News.

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