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  • Long-awaited ACO Rule Released

    The US Department of Health and Human Services (HHS) today released its much anticipated proposed rule for Accountable Care Organizations (ACO). The proposed rule defines eligibility requirements of ACOs, the types of providers that may be included in an ACO, how providers can participate in this new model of care, and criteria that will be used to reward ACOs that lower growth in health care costs while meeting delineated performance standards. 

    Under the proposed rule, an ACO refers to a group of providers and suppliers of services that coordinate care for the patients they serve under Medicare parts A and B. According to the proposed rule, ACOs and the incentives offered to them will encourage health care providers to work together to treat an individual patient across care settings. In turn, the Medicare Shared Savings Program will reward ACOs that lower growth in health care costs and that meet delineated performance standards on quality of care incentives measures and patient centeredness criteria. According to HHS, ACOs will develop in various innovative ways, according to the unique needs of each community.

    Patient and provider participation in an ACO is purely voluntary. Beneficiaries would not enroll in a specific ACO. Instead, the proposed rule calls for Medicare to take a retrospective look at the beneficiary's use of services to determine whether a particular ACO should be credited with improving care and reducing expenditures. Additionally, patients assigned to an ACO also have the option of receiving services from providers who are not ACO providers. 

    Providers participating in an ACO would be required to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care delivered to the beneficiary.

    As a companion to the proposed rule, CMS and the Office of Inspector General have also released a notice with comment period that addresses how certain waivers will allow ACOs to provide care while not violating the physician self-referral law, anti-kickback statutes, or the civil monetary penalties law. In addition, the Federal Trade Commission has released a proposed statement of its anti-trust policy as it relates to ACOs.  

    Upon the release of the proposed rule, CMS Administrator Donald M. Berwick, MD, participated in a public forum in which he provided an example of a patient receiving cardiac rehabilitation services from a physical therapist within the ACO model.    

    APTA is carefully reviewing the proposed rule and will provide members a comprehensive analysis and summary of the rules shortly. The association also will submit its recommendations on the rules via the public comment period.   


    • You never cease to amaze me. We have supposed to be coordinating care since the beginning of time. Working with CMS is a death sentence. They have no idea of what they are doing. I have been licensed since 1969. Quality of care improved up to the early 1980's and has gone downhill since;m because of CMS; hospital greed and Pt's ignorance and the APTA foolishness.

      Posted by Don Mormile on 4/1/2011 2:15 PM

    • It seems like hospital systems are the big winners here. If you are not an outpatient clinic or home health agency associated with the hospital, you are locked out in all practical terms. Do I see this wrong?

      Posted by John Baker on 4/1/2011 5:14 PM

    • Here at the other end of the country (FL) we have been dealing with CMS more intensively than most, primarily because we are viewed as operating in Fraud-Central. I think the APTA has done yeoman service in practice and reimbursement. The quality of services has not gone down, just the reimbursement and autonomy....same for all the heatlh professions. PPS, Pay-4-Performance, HMO-type arrangements are inevitable and we need to be up to date and involved as these inexorably develop. That or be on the outside looking in as unqualified semi-professionals offer what look like our services for lower prices. I'd rather know up-front what I can expect in reimbursement and have the ability to control utilization and quality myself, rather than the current haphazard, post-payment, review-by-nontherapists, oversight. Just spent 19 months getting paid for legitimate services because we had to go all the way to Admin. Law Judge to get a favorable finding! I'm ready to follow the Assoc's lead and accept all the help they can offer.

      Posted by Ken Amsler on 4/1/2011 9:04 PM

    • How is this rule going to do anything other then be the death of independent practitioners. I am for finding models of care that decrease cost and improve outcomes, but this idea seems to drive all care to large organizations that have been cost increase engines and often just average care. I have seen more interest in innovative high quality care from the independent practice providers then in large organizations. I hope the APTA fights for the independent practice and it's ability to be an efficient care provider. Centralization leads to less choice, less innovation, poorer competition, and ultimately a degraded health care marketplace.

      Posted by Paul Abler on 4/2/2011 11:45 AM

    • I agree with Paul. It worries me that everything is being pushed toward large organizations and that self-referral and anti-kickback statutes will be waived in this arrangement. I feel that will inevitably open up more fraud and increased utilization as these organizations will find ways to adjust their practice models so that they appear to improve outcomes, but really with the main goal of maximizing profit. Truly, the private practitioner is at a disadvantage. In all my 12 years of experience as a physical therapist, I've seen the highest quality of care come from private practice. Everything in these times is being consolidated into hospital systems not because of better outcomes, but because of survival. Reimbursement is on a steady decline forcing more patients to come through in less time to maintain a profitable business. It inevitably leads to decreased quality and I dont see how creating ACOs will change that.

      Posted by Dino Bolos on 4/3/2011 2:04 AM

    • Dino nails it when he says "I feel that will inevitably open up more fraud and increased utilization as these organizations will find ways to adjust their practice models so that they APPEAR to improve outcomes." The ACO model reeks with opportunity for fraud. Policing every aspect of this plan will raise healthcare costs and decrease quality; and fraud will still raise its ugly head.

      Posted by Edie Watson on 4/4/2011 12:32 AM

    • There needs to be a system with less governmental oversight. More oversight means more expense. Rather than creating a whole new system, we should police our current system first to get rid of fraud and abuse. This goes for governmental waste and abuse as well. Also, there needs to be tort reform to reduce frivolous lawsuits. Quality care comes from every single healthcare provider that has been trained to provide the care. There needs to be an increased trust among ourselves to do what is right in all situations and when someone is creating a fraudulent situation, they need to be held accountable for their actions. Finally, after the previously discussed issues have been addressed, then it would be appropriate to look at additional ways to control healthcare costs while providing the highest standard of care.

      Posted by Scott Gibson on 4/4/2011 7:34 AM

    • Solo practice and smaller practice with low overhead can only give quality care..there is no incentive to see good outcomes with large practices where volume is all that matters quality is not a criteria.I have seen locally a CVA patient seen for 5 months by such a big Clinic with patient still in the wheelchair..how was the treatment justified?say after 2 months..this same patient who I happened to get as a Home health patient was able to ambulate in less then 2 weeks..The ignorant patient here is taken fully advantage off..With Medicare not requiring any documentation..the system is milked to the max!

      Posted by SHYAM ULLAL,PT on 4/5/2011 12:31 AM

    • Big organizations usually concentrate decision making and healthcare organizations are especially susceptible to this threat because they already concentrate medical decisions at the top of the medical hierarchy - the physician. I think ACOs can succeed if they distribute decision making to mid-level providers like physical therapists, nurses and physicians' assistants. One barrier to successful ACO implementation will be physicians' organizations lobbying against expanded scope-of-practice legislation at the state level. Tim

      Posted by tim richardson on 5/3/2011 3:25 PM

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