To succeed in the proposed Medicare Shared Savings Program, the smallest accountable care organizations will have to save 3.9 percent above the savings benchmark and, on a sliding scale, the largest ACOs will have to save 2 percent above the benchmark.

But 2 percent was the threshold to meet in similar programs the government piloted in recent years and it was tough to meet, recalls Chet Speed, vice president of public policy at the American Medical Group Association, which represents specialty or multi-specialty practices. "Many sites felt that was a significant obstacle to shared savings." Consequently, 3.9% under the new proposed program would be "very difficult" to achieve, he adds.

Alexandria, Va.-based AMGA also has concerns about proposed risk adjustments for patient populations in an ACO. The Centers for Medicare and Medicaid Services will provide a risk adjustment for the first year, but not years two and three. That means that if ACOs attract sicker patients--which they are designed to do and the fundamental reason for their being--and there aren't risk adjustments, then ACOs' payments for meeting savings thresholds won't rise in the second and third years.

Another concern: Beneficiaries in Shared Savings ACOs can opt out of their Medicare claims data being shared with providers. But it's not clear if the opt-out pertains just to providers within the ACO, providers outside the ACO, or within and outside the ACO.

Still, CMS is asking for a lot more comment on various proposals than it normally does in proposed rules, so there is opportunity to affect change in many areas of the rule, Speed notes.

--Joseph Goedert


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