The federal government has adopted a number of changes recommended by APA to its final rule on accountable care organizations (ACOs)—changes that are aimed at reducing the risks inherent in starting an ACO as well as easing burdensome reporting measures and allowing ACOs to keep a greater share in the money saved.

As part of the new health reform law— the Patient Protection and Affordable Care Act—ACOs are designed to encourage more integrated care for Medicare beneficiaries and to improve care while reducing costs. In response to a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) in March outlining rules for ACOs, APA provided the agency with detailed analyses and recommendations.

In its final rule issued in October, CMS adopted APA’s recommendation that people with mental illness, including substance use disorders, be included in what are defined as “at risk” beneficiaries who must be protected against discrimination and assured access to high-quality health care. In addition, CMS acknowledged the need for more mental health and substance abuse quality measures and will work on developing them with input from interested parties.

The agency also adopted recommendations aimed at making it easier for physicians—especially those in small group practices—to participate. “When CMS released its proposed ACO rule in March, ACO participation seemed nearly unachievable to many physicians, including those who work for large multispecialty practices and health systems,” Julie Clements, deputy director for regulatory affairs in APA’s Department of Government Relations, told Psychiatric News. “Our assessment is that the revised rule, published in the Federal Register on October 20, provides a better opportunity for physicians, including those working in smaller practices, to participate in the ACO Medicare Shared Savings Program.”

Here are highlights of the final rule:

• The standard financial model for ACOs will still be shared savings, and the program will function essentially as a pay-for-performance program.

• There are specific provisions supporting participation by physician-owned organizations and rural providers.

• There will no longer be requirements to withhold shared savings payments to cover potential future cost increases.

• ACOs will be allowed to share in savings beginning with the first dollar of savings earned.

• There will be 33 quality measures instead of the 65 originally proposed. In the first year, ACOs will be required to report only that they have recorded the quality measures (“pay for reporting”); in the second year they will be required to report savings (“pay for performance”).

• ACOs will have more advanced knowledge of what kind of beneficiaries make up their pool than under the old rule.

• The requirement that at least 50 percent of an ACO’s primary care physicians be “meaningful users” of electronic health records was eliminated.

• There will be a rolling application process. The 2012 start-up date for ACOs has been pushed back from January 1 to either April 1 or December 1.