ACOs is the hottest four-letter word in health care
Accountable care organizations take up only seven pages of the massive new health law yet have become one of the most talked about provisions. This latest model for delivering services offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs.
What is an accountable care organization? An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. In the new law, an ACO would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.
Why did Congress include ACOs in the law? As lawmakers search for ways to reduce the national deficit, Medicare is a prime target. With baby boomers entering retirement age, the costs of the program for elderly and disabled Americans are expected to soar. ACOs make providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work they have to seamlessly share information. Those that save money while also meeting quality targets would keep a portion of the savings. Providers can choose to be at risk of losing money if they want to aim for a bigger reward, or they can enter the program with no risk at all.
How would ACOs be paid? In Medicare’s traditional fee-for-service payment system, doctors and hospitals generally are paid more when they give patients more tests and do more procedures. That drives up costs, experts say. ACOs wouldn’t do away with fee for service but would create savings incentives by offering bonuses when providers keep costs down. Doctors and hospitals would have to meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers would get paid more for keeping their patients healthy and out of the hospital. If an ACO is not able to save money, it could be stuck with the costs of investments made to improve care, such as adding new nurse care managers, and also may have to pay a penalty if they don’t meet performance and savings benchmarks. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help them build the infrastructure necessary for coordinated care – a concession the Obama administration made after complaints from rural hospitals.
Who’s in charge — hospitals, doctors or insurers? Hospitals, primary care providers and other physicians are in charge of an ACO, but insurers can also play a role. Some regions of the country, including parts of California, already have large multispecialty physician groups that may become an ACO on their own, likely by networking with neighboring hospitals.
What can go wrong? Many health care economists fear that the race to form ACOs could have a significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs.
ASA Clarifies EHR Program Rules
By Justin Vaughn, M.Div, CPC 12/7/2012
Recently, the ASA published a set of frequently asked questions (hereinafter, FAQ) regarding anesthesiologists and the EHR Incentive Program; and, in so doing, has finally put to rest some nagging questions I had submitted to the society over the preceding weeks. As we earlier reported, the Final Rule for Stage 2 of Meaningful Usecontained a codicil exempting anesthesiologists from the program’s penalties over a 5-year period. This was good news, but the wording of the Rule raised a few questions:
- Was the exemption automatic or would the anesthesiologist have to file a request?
- If a request has to be filed, when is the deadline and what is the process for filing?
- Does the exemption from the penalty automatically exclude the anesthesiologist from participation in the incentive portion of the program?
ASA personnel had informed me that, after consulting with CMS, my questions would be addressed in an upcoming FAQ. That document is now posted on the ASA website, and contains the following highlights:
- The annual exemption from the penalties (which start in 2015) that applies to anesthesiologists is automatic, and is automatically renewed each of the 5 years of the exemption period. Therefore, you will not have to file for the exemption—as long as anesthesiology is listed as your primary specialty in CMS’s Provider Enrollment, Chain and Ownership System (PECOS).
- Having an automatic exemption from the penalty does NOT preclude you from participation in the program. In other words, you can still attempt to earn the incentive payment even though you are not subject to the penalty.
- CMS will audit those attesting to meaningful use (MU), and will not only recoup incentive payments erroneously made, but could impose penalties if willful intent to defraud is demonstrated. Therefore, do not attest (legally certify) unless you are confident you have indeed met the MU criteria.
- For anesthesiologists who practice in multiple locations (some of which may not have EHRs), and who wish to participate in the incentive program, CMS states:
“. . . an EP must have 50 percent or more of his or her outpatient encounters during the EHR reporting period at a practice/location or practices/locations equipped with [certified EHR technology (CEHRT)]. An EP who does not conduct at least 50 percent of their patient encounters in any one practice/location would have to meet the 50 percent threshold through a combination of practices/locations equipped with CEHRT.”
Though the ASA advised in its FAQ that it will neither support nor oppose an anesthesiologist’s decision to participate in the EHR program, the clarifications it elicited from CMS will at least lend a bit more light to those still considering the best course of action for them and their practice.
The information presented herein reflects general information that is current as of the date it was first published. In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.
