The move toward accountable care organizations kicks in high gear with the Oct. 20 issuance of final Medicare ACO rules from the Centers for Medicare and Medicaid Services.

These include a final Medicare Shared Savings Program: Accountable Care Organizations rule, and an interim final rule removing certain barriers to ACO participation by establishing waivers to federal physician self-referral and anti-kickback laws. The rules are available here and will be published Nov. 2, 2011, in the Federal Register.

CMS also has launched the Advanced Payment model to enable physician-owned and rural providers participating in the Medicaid Shared Savings program access to their shared savings up front to make infrastructure and staffing investments. Advance payments would be recouped from future achieved shared savings.

In the final rule, CMS estimates 270 ACOs participating in the Shared Savings program, about double what was previously estimated. Changes in the Shared Savings program under the final rule include:

* The proposed rule called for the reporting of 65 quality performance measures, many of which presently do not exist or have not been adequately tested. CMS in the final rule picked 33 quality measures "which will be scored as 23 measures."

* Meaningful use of electronic health records will be a measure, but the 50 percent threshold of physicians achieving meaningful use is dropped.

* ACO participation by rural health centers and federally qualified health centers has been added.

* While patient satisfaction surveys from the Consumer Assessment of Healthcare Providers and Systems are required in the final rule, CMS will pay for the first two years of CAHPS surveys.

* New flexibility in the start date of ACOs, which was proposed as Jan. 1, 2012. Now, CMS will accept applications for an April 1 or July 1 start date, with all ACOs starting in 2012 having agreement periods that terminate at the end of 2015. This gives a "first performance year" of 21 months, ending at the end of 2013, for ACOs starting in April 2012; and an 18-month first performance year for ACOs starting in July 2012.

* The proposed rule required an ACO have at least 5,000 Medicare fee-for-service beneficiaries assigned to it, a clear mandate under the Affordable Care Act.  But an "expanded methodology" in the final rule should make it easier for ACOs in smaller and rural markets to meet the threshold. CMS acknowledges that some specialist physicians often also are the primary care physician for patients with certain conditions or in rural areas. Consequently, beneficiaries without a PCP "may be assigned to an ACO on the basis of primary care services provided by other physicians," according to the rule. This enables consideration of all physician specialties in the ACO assignment process, making it easier for some to reach the 5,000 mark.


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