Stipulations under the proposed rule for accountable care organizations that require half of participating primary care physicians to be meaningful users of electronic health records by the second year are unrealistic, says Cecil Wilson, M.D., president of the American Medical Association.

That was one of several issues Wilson raised during a conference in Chicago. Addressing a group of physicians and attorneys gathered for the American Bar Association's annual conference on health law, Wilson said that the ACO concept has potential to improve care and lower costs, but that the proposed rule was laden with problems that would, in effect, block widespread participation. Among them are the "retrospective attribution" provisions of the program, in which patients participating in the Medicare payment model would only be identified after the fact. In the Shared Savings ACO model, Medicare would return a portion of any savings from reduced costs to providers, while simultaneously exposing providers to a certain amount of risk for delivering quality outcomes.

Several other panelists raised objections to the proposed ACO rule as well. The cost of entry to program--a number that is in dispute--would effectively block physician practices from launching an ACO, noted David Hilgers, a partner in Brown McCarroll, an Austin, Texas-based health law firm. "ACOs are too complicated and not going to work for doctors," he said. For one thing, physician groups are strapped for capital, he said. That is a major hurdle for them in acquiring the kind of EHR technology that is instrumental to the care coordination required to make an ACO work.

Another challenge that physicians face is the unprecedented amount of change foisted on the industry by the federal government. "Physicians are inundated with information," said panelist Ben Armstrong, director of physician relations at Advocate Illinois Masonic Medical Center, a Chicago area hospital that is part of Advocate Health Care, a large delivery system. He cited the example of a local group practice that has had sales calls from some two dozen EHR vendors. Advocate has its own ACO effort underway with Blue Cross and Blue Shield of Illinois, which is built around a shared savings model. The effort is driven by physicians, who vote on quality measure adoption, Armstrong said. 

Hilgers and other panelists laid out options for group practice arrangements, including hospital-based employment, formation of independent practice associations and concierge medical groups. While many physicians are struggling economically, those that can carve out an effective niche will do well, they said. "Theoretically, primary care doctors ought to have a lot of power," Hilgers noted, citing the shortage of physicians there. "Outpatient clinics will become predominant. There is a lot of potential here."


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