What follows is extensive commentary on the Shared Savings Program proposed rule from Justin Barnes, vice president at physician software vendor Greenway Medical Technologies and past chair of the HIMSS Electronic Health Record Association, a vendor trade group:
"With its highly publicized start date of Jan. 1, 2012, the most anticipated, and maybe the most hopeful, healthcare delivery and cost containment proposal since the meaningful use incentive plan for health care technology gains arrived on the eve of April Fools' Day.
"But it's no joke that among 47 million U.S. Medicare patients, one in five that are hospitalized are readmitted within 30 days, and that most suffer from more than one chronic ailment, which largely contributes to annual healthcare costs approaching $2.5 trillion. Rising healthcare costs, expected to grow another 10 percent this year, have outpaced gains in Gross Domestic Product for many years.
"The proposed Shared Savings Program forming accountable care organizations seeks voluntary three-year commitments from primary care and/or multi-specialty physician groups, hospitals, home health services, rehabilitation centers and other institutions to form communities of health committed to serving at least 5,000 patients for an initial three-year period.
"Will those numbers add up? The Centers for Medicare and Medicaid Services' proposed rule rightly envisions a system of care coordination, non-duplicate testing and preventive medicine based on financial levels of benchmarking to trigger shared savings. Essentially, the ACO model takes a logical approach by building upon existing Physician Quality Reporting System and Hospital Inpatient Quality Reporting programs, and of course the burgeoning meaningful use program. These are established initiatives that are, at their heart, systems of improved patient care through quality reporting and provider incentives based on care coordination through innovative technology, namely the electronic health record.
"It's very clear that accountable care is aligned with meaningful use because within the proposal, by year two of Shared Savings, at least 50 percent of primary care providers are to be meaningful EHR users of EHRs. This optimistic element of the proposed rule should receive sizable reaction in the public comment period commencing now through June 6. Not only will this provision add pressure to the Stage 1 success of meaningful use EHR adoption and its own quality reporting metrics, but could also add another layer of complexity to EHR certification. This is something we will need to closely watch.
"To that end, the proposal's establishment of a range of 65 quality measures grouped within five categories (care coordination, patient safety, preventive health, at-risk and elderly patient focus, and patient/caregiver interaction) is another aspect of alignment with meaningful use. Details aside, this is a practical and achievable approach, and providers need to have faith that today's leading technology and EHR providers can deliver.
"And like the meaningful use program, additional shared savings are available for providers in ACOs that include patients receiving care in Federally Qualified Health Centers and Rural Health Clinics during a performance year.
"Technology integration, data sharing and interoperability can and will bring the communities of health models to life. Here is where CMS, ONC and many other agencies are combining programs to truly create a smarter, more sustainable healthcare system. The proposal also shows its teeth by setting a minimum benchmark rate of two percent before savings are shared. We know that longstanding ACO models such as those undertaken by the Mayo and Cleveland clinics are workable, and it's also noteworthy that this proposal seeks to embrace knowledge and experiences from private payers.
"I am particularly pleased to see the expected flexibilities included in the proposal: voluntary participation by providers, a clear message to patients that ACOs are not the creation of in-network doctors, a system of allowing beneficiaries to opt out of data sharing, and no changes to patients' current benefit structure.
"The proposal also offers risk and reward choices so that ACO participants can find their own levels of confidence. This is a good aspect of the proposal because care providers already utilizing EHRs at the point of care can choose to take on greater reward and greater risk throughout the three-year commitment, while those still braving the new world of health I.T. can ensure smaller rewards in years one and two, and take on the risk of below-benchmark penalties only in year three.
"Providers must also weigh factors such as just how compliant with care plans their patients really are, and keep in mind that unlike the meaningful use program, there are no direct provisions to aid in deflecting startup technology costs such as hardware, interoperability functions and operational needs. Therefore stakeholders must assess their current status and planning for the separate yet increasingly intertwined meaningful use incentive opportunities.
"As ambulatory providers, hospital administrators and leaders of other healthcare institutions review their options, I believe they can feel secure that a commitment to clinical, financial and administrative integration is wholly achievable through today's leading health I.T. platforms and interoperable EHRs offering solutions such as patient portals, automated referrals, clinical alerts, outcomes reporting and management, orders tracking and analytics.
"In his comments upon release of the proposed rule, CMS Administrator Donald Berwick noted that the Medicare Fee For Service structure plays a role in our currently fragmented healthcare delivery system, yet the proposal clearly states that FFS parts A and B will remain in place. Stakeholders will be interested in how these payment elements can be reconciled to achieve the goal of Shared Savings and ACOs putting the brakes on rising costs.
"And I cannot blame CMS for allowing the ACO models to be voluntary for both providers and patients. Regulatory, anti-trust and tax issues remain, as well as anticipated discussion on the below-benchmark penalties included in the two tracks of Shared Savings being offered.
"I hope that providers closely study the success their peers have had with PQRS and meaningful use to date - where in the latter program some $40-$50 million in CMS Medicaid incentives have ready been issued - and understand that Shared Savings is a quality reporting system with a delivery, reporting, coordination and health IT structure that is already in place and has been shown to succeed in several arenas.
"If we take a look back at the original meaningful use proposals (remember how complicated and somewhat controversial they seemed?) and then further recall the post-commentary polish that led to a final rule, then accountable care can be seen as another major step toward a truly advanced and sustainable healthcare system in America."
(Health Data Management at 1:00 p.m. Eastern Time on April 5 will host a Web seminar with health law attorneys Bruce Fried and Robert Slavkin examining provisions of the Shared Savings Program proposed rule. Click here for more information.)
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