ACO rules need careful setup, groups tell federal agencies

Antikickback laws, antitrust laws and other federal rules have become major sticking points as government agencies write the rules for accountable care organizations.

Organizations representing physicians, including the American Medical Association, are calling for relief from antitrust laws so that small practices can establish various versions of ACOs and maintain some independence.

"Most of the care is provided by physicians in groups of nine or fewer," said AMA President Cecil B. Wilson, MD. "What we hope will happen is that the regulations, when they are released, will allow flexibility and not require a one-size-fits-all approach so that physicians in small groups can come together and improve the quality and reduce the growth in health care spending."

Those speaking for insurers, such as America's Health Insurance Plans, are calling for a more cautious approach to reduce the chance that any ACO will become so large as to fix prices and aggregate market power.

"If the agencies conclude that there are barriers that can be addressed, we encourage them to do so in a narrow fashion to ensure that consumer protections are not lost in the process," wrote Joseph Miller, the organization's general counsel, before a government workshop on the subject on Oct. 5 in Baltimore.

AMA requested conference

The conference was hosted by the Federal Trade Commission, the Centers for Medicare & Medicaid Services and the U.S. Dept. of Health and Human Services Office of Inspector General. The AMA had requested the conference. About 300 people were in attendance, and many more listened in or contributed by phone and on the Internet.

Information gathered from this group and others representing nurses, medical groups, the business community and hospitals will be viewed during the rule-making process.

"We were very pleased, because this is an important issue," Dr. Wilson said in a telephone interview after the meeting. "How accountable care organizations will be constructed, what the regulations will be, are all very important as part of health system reform."

The establishment of shared savings programs and ACOs for Medicare and Medicaid beneficiaries is a key part of the new health reform law.

"The basic thrust of it was to ask a series of questions about the implications of the law and what kinds of additional rules that CMS should establish or policy changes the FTC should make. ... [The agencies] asked communities about how to make the law work most effectively and prevent undesirable outcomes," said Harold D. Miller, executive director of the Center for Healthcare Quality and Payment Reform in Pittsburgh, one of the attendees.

Setting up accountable care organizations has generated much discussion from many parts of the health care system, because ACOs require some form of alignment and a focus on a continuum of care rather than a single episode.

Physicians still earn a fee for services provided but are also eligible for bonuses determined by cost-saving and quality metrics, which have yet to be set.

Health system reform legislation calls for ACOs to be established by Jan. 1, 2012. The law states that eligible entities include group medical practices, networks of individual practices, partnerships or joint venture arrangements between hospitals and health care professionals, hospitals that employ physicians and other multiparty arrangements as deemed appropriate. An ACO must run for at least three years and care for at least 5,000 patients.

Government agencies are working on defining other aspects of the payment model, including exactly what an ACO is and how bonuses will be determined.