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.