APA Urges Major Changes in Government's ACO Rule

APA is urging the federal Centers for Medicare and Medicaid Services (CMS) to revise its proposed rule regarding the structure and function of accountable care organizations (ACOs) to make physician participation easier and less financially and administratively burdensome and to make beneficiary participation in ACOs voluntary.

In a nine-page letter to CMS Administrator Donald Berwick, M.D., APA Medical Director James H. Scully Jr., M.D., submitted extensive comments responding to the agency's proposed rule, issued in March, describing the nature and function of ACOs (see ACO Rule Modifications Suggested).

"As currently written, the proposed rule would burden most psychiatrists and other physicians in general wishing to enter into an ACO with prohibitive start-up and maintenance costs, much risk, and too-limited shared savings," Scully said.

ACOs are a model for coordinated delivery of medical care within a reformed health care system and were designated for a demonstration project (known as the Shared Savings Program) in the Patient Protection and Affordable Care Act signed by President Obama last year.

Generally, ACOs are coalitions of physicians and hospitals responsible for coordinating medical care for populations of patients across the continuum of care; they agree to be accountable for improving the health and experience of care for individuals, as well as the health of populations, while reducing the growth rate in health care spending.

In the proposed rule, CMS outlined 65 performance measures for establishing the standards ACOs must meet under the Shared Savings Program. The measures span five quality domains: patient experience of care, care coordination, patient safety, preventive health, and at-risk population/frail elderly health. Included in the preventive-health domain is a measure for depression screening (Psychiatric News, May 6).

APA's comments hew closely to those submitted last month by the AMA, but also include comments related to aspects of the government's rules for ACOs that are especially relevant to psychiatry. The APA comments cover beneficiary assignment, quality-measure reporting requirements, start-up and maintenance costs associated with ACOs, the role of specialists, treatment of "at-risk" beneficiaries, the risk structure of ACOs, electronic health records, and the handling of patient data. (For excerpts of APA's comments, see ACO Rule Modifications Suggested).

Chief among APA's comments were those regarding the assignment of beneficiaries to ACOs. The way in which beneficiaries are assigned, as described in the proposed rule, is confusing for physicians and patients alike, Scully said in his letter.

APA Says Participation Must Be Voluntary

APA also urged the government to make beneficiary participation in ACOs voluntary. "The proposed rule must be modified to provide patients with a clear understanding of how they become participants in an ACO," Scully said. "APA asks for the issuance of an Interim Final Rule that clarifies the process by which beneficiaries are assigned to an ACO, so this process is understandable to an adult with reasonable, ordinary decision-making abilities as well as to a psychiatric patient characterized by limited capacity to provide informed consent for his or her treatment within an ACO."

Quality-Reporting Issues Raised

APA also had extensive comments about the reporting of quality measures. The Association is urging the government to refine its list of quality measures, shortening it from the present 65, but also including measures that are more pertinent to psychiatry. "APA asks CMS to incorporate more measures relevant to the daily practice of psychiatry in its formula for calculating the ACO performance threshold," Scully wrote. "Examples of measures relevant to psychiatry include a major depressive disorder medication-management measure and an ACO e-prescribing measure."

He added, "While APA supports including depression screenings as a quality performance measure in the preventive health category, it recommends that CMS specify that depression screenings be performed by physicians."

One of the most persistent concerns among physicians about ACOs has been the high costs associated with start-up and the difficulty costs pose for physicians working in solo or small-group practices. APA noted in its comments to CMS that of the 10 physician groups that participated in the ACO demonstration projects, the vast majority were large physician groups.

"The high costs that accompany the formation and execution of an ACO are not practical for a small group of physicians," Scully emphasized in the letter. "Most of APA's members work in small practice settings. These psychiatrists' practice settings are rarely affiliated with big hospital systems that have the resources to enter into an ACO. The high start-up and maintenance costs stemming from an ACO could make it impossible for many psychiatrists to enter into an ACO."

APA's letter to CMS is posted at <http://www.psych.org/MainMenu/AdvocacyGovernmentRelations/GovernmentRelations/RegulatoryComments/APA-Comments-on-Accountable-Care-Organizations-Proposed-Rule-6711.aspx>.