ACO Rule Modifications Suggested

Following are excerpts from APA's letter to the Centers for Medicare and Medicaid Services (CMS) regarding the function and structure of accountable care organizations (ACOs).

Beneficiary Assignment

• APA believes few physicians, even when combining beneficiaries, will satisfy the minimum threshold of 5,000 participants mandated by CMS to launch an ACO.

• APA urges CMS to adopt a prospective approach that permits Medicare beneficiaries to voluntarily elect to be part of an ACO.

• APA asks for 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 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 Measurement Reporting Requirements

• APA asks that CMS align the quality measures and reporting requirements for ACOs with those in other government incentive programs, such as the Electronic Health Record Incentive Program, and Physician Quality Reporting System.

• APA believes 65 quality measures are too many measures for an ACO to report on following the first year of performance. APA instead recommends that CMS require satisfaction of fewer measures in the first two years of the ACOs.

• APA asks CMS to incorporate more measures relevant to the daily practice of psychiatry in its formula for calculating the ACO performance threshold. Examples of measures relevant to psychiatry include a major depressive disorder medication-management measure and an ACO e-prescribing measure.

• 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.

Start-Up and Maintenance Costs

• The high start-up and maintenance costs stemming from an ACO could make it impossible for many psychiatrists to enter into an ACO. Additionally, the requirement that 25 percent of the savings realized by ACO participants be held in escrow to ensure possible repayment of losses to Medicare further heightens the financial risks to psychiatrists seeking to enter into an ACO.

ACO Risk Structure

• APA believes a greater number of physicians will be able to participate in an ACO if CMS does not require all ACOs to be liable for financial losses at some point in the three-year ACO contract.