Editor’s note: See additional posts on the Medicare Shared Savings Program Final Rule and related delivery system and payment reform initiatives by Lawrence Casalino and Stephen Shortell, Douglas Hastings, and Mark McClellan and Elliott Fisher, and Don Berwick and Richard Gilfillan.
Last week, the Centers for Medicare and Medicaid Services (CMS) may have done what once seemed impossible. Its final rule on Accountable Care Organizations (ACOs) seems to have put an end to the rancor and bitter debate on this particular issue, shaping a framework that just about all parties can accept.
By responding thoughtfully to comments on the proposed rule, and balancing competing interests, the agency has given us a welcome respite from the pitched battles that are raging over so many aspects of health reform. But the real measure of success will be whether successful ACOs are soon in place, providing better-coordinated, more patient-centered care for millions of patients and giving us all a way to get better value for our health care dollars.
We believe last week’s announcement will encourage more providers to participate in this program. From the perspective of consumers, we applaud the strong emphasis on patient-centered criteria that should pave the road to better care. And especially as advocates for our oldest, sickest and highest risk patients, we applaud this effort to incentivize better primary care, increased coordination, and shared accountability across providers. From the perspective of purchasers, we believe that CMS has crafted a foundation to hold providers accountable for quality performance and cost savings, and created a path to move providers away from today’s perverse fee-for-service system.
We are very pleased that this final rule will require ACOs to use beneficiary experience of care and outcome measures to evaluate performance. We believe CMS landed in a better place with respect to the quality measures ACOs must report on. While we appreciated the comprehensiveness of the original list of 65 measures, there were a number of measures that added minimal value. The final list of 33 measures is a stronger set that focuses on highest impact measures and, very importantly, includes measures of patient experience, functional status and clinical outcomes, care coordination and safety. We would, however, have liked pay-for-performance to occur sooner in the program, especially for measures that are already in use. Finally, we are very pleased that this final rule continues to ensure full transparency, notification and choice for beneficiaries. These provisions are all essential to engaging consumers in a positive way and realizing the promise of successful ACOs.
Nobody got everything they wanted in the final rule and we, too, have concerns. We are disappointed that the upfront anti-trust review process is no longer mandatory, but glad there is strong acknowledgement that there must be close monitoring for any signs of cost-increasing market concentration. We are glad to see that the final rule requires CMS to share ACO applications and new types of data that will strengthen the ability of the Federal Trade Commission and Department of Justice to assess and monitor the market impacts.
It is also unfortunate that the provisions requiring beneficiary participation on ACO boards have been tempered, rather than expanded to include representation from a diverse range of community stakeholders, including purchasers, labor and community-based groups. It is now incumbent on CMS to closely monitor ACOs to ensure that they reflect the community interests they are intended to serve, and that consumers, beneficiaries and other key stakeholders are engaged in the design, governance and evaluation of their performance. Consumers and purchasers hope and expect that these provisions will be strengthened down the road if needed.
Every leader from every sector has a list like this – things they like, and things they don’t like, in the final rule. But the time for tallying who won and who lost, and by how much, is over. Now it’s time for all parties to come together to create successful ACOs that deliver care that is patient-centered, that improves quality and care coordination, and that lowers costs. The stakes are too high to let anything stand in our way, or to let opponents of reform exploit any remaining differences.
We said before this rule was released that it’s time for a new dynamic where we come together to implement the reforms the nation so urgently needs. ACOs are one of many promising models and initiatives that will be tested by the CMS Innovation Center over time. It is well past time to leave our broken, dysfunctional health care system behind and give the Accountable Care Organization model the test it deserves.
The final rule gives us a chance to do that. That’s all we could ask. CMS has done its part. Now it’s time for the rest of us to do ours. If we do, patients, their families and family caregivers, our economy and our nation will benefit.