2011-10-25 14:39:29 UTC

How Will ACO Final Rule Impact Your Practice?

Oct. 27, 2011

AGA experts have reviewed the accountable care organization rule released last week by CMS and offer important insights about the implications for specialists.

AGA experts have reviewed the accountable care organization (ACO) rule released last week by CMS and offer important insights about the implications for specialists. It is essential that gastroenterologists keep track of this issue since ACOs have the potential to shape the future health-care system. AGA is pleased that CMS considered our comments to the proposed rule and included many of our recommendations in the final rule. Compare CMS’ changes to the ACO rule in response to AGA’s comments.

The Medicare Shared Savings Program (MSSP) establishing ACOs provides incentives for participating health-care providers who agree to work together to achieve measured quality improvement and reductions in the rate of spending growth. Although the focus of the MSSP still centers on the provision of primary care services, specialists can participate in the MSSP as either an owner, an ACO CEO, an ACO participant, a member of the ACO governing body, a senior level medical director, or part of the physician-directed quality assurance and improvement program.

Through several modifications in the final rule, CMS addressed the role of specialty physicians under ACOs, including:

  • Adding a stepwise beneficiary assignment process. CMS acknowledges that specialists appropriately provide primary care services for beneficiaries with serious and/or chronic conditions. As a result, CMS will implement a “stepwise” beneficiary assignment that will allow patients to be assigned to specialists, as long as they have not received a primary care service from a primary care physician during the most recent year.
  • Maintaining key quality measures that emphasize the need for specialty care and the creation of an “access to specialists” module. As a result of comments, CMS reduced the number of quality measures from 65 to 33. Of the 33 measures, two measures have a direct impact on GI care. They are consumer assessment of health providers and systems: access to specialists, and colorectal cancer screening. CMS also announced its intent to add an “access to specialists” module to emphasize the importance of specialist care in ACOs.
  • Clarifying referral relationships. While the MSSP maintains the beneficiary's freedom under the Medicare fee-for-service program to choose any participating Medicare provider, CMS acknowledged that there will be an incentive for ACOs to require that referrals be retained among the ACO, ACO participants and ACO providers/suppliers. CMS’ initial proposal restricted any specific referral arrangements. However, CMS modified its proposal to provide limited exceptions for referrals permitted under the physician self-referral law. CMS will monitor the actions of ACOs to determine whether an ACO, its ACO participants or its ACO providers/suppliers are interfering with the beneficiary's freedom of choice by improperly limiting or restricting referrals and care to ACO participants or ACO providers/suppliers in the same ACO.

Read more about the role that specialty physicians can play in ACOs.

AGA will continue to review and analyze the final ACO rule and how it will affect the practice of gastroenterology and patient care. Continue to read AGA eDigest to learn more.

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