Monday, March 15, 2010

Accountable Care Organizations & Criteria For Piloting Them in the House Reconciliation Bill: Include Disease Management & the PCMH

In another step in the high political theater of arm twisting, outright threats, secret deals, back-stabbing, towel snaps, shifting voting blocs and It Takes Courage high rhetoric, the U.S. House of Representatives' Budget Commitee has passed the 2000 plus page reconciliation legislation, which is aptly named.....(surprise) "The Reconciliation Act of 2010." It may or may not be the real thing, but hey... it's something.

That legislation was only just posted in the last 24 hours and, unlike many of the House members, the DMCB is still reading through it. A first step was to make sure "Accountable Care Organizations" (ACOs) are still included. Your diligent Disease Management Care Blog performed a scan and is happy to confirm that the concept is still there, namely in Section 1301 on page 453. ACOs will be "piloted" with two purposes: 1) reduce expenditures and (not or) 2) improve health outcomes, by a) promoting provider accountability, b) encouraging infrastructure and c) rewarding quality/efficiency. The pilots are supposed to start January 1, 2012 and last 3-5 years.

The DMCB is still confused by the notion of a "pilot." A superficial review of the bill fails to precisely define it, but the language mentions what may be a key determinant for the ACO pilot: the HHS Secretary may issue regulations that permanently implement ACOs, apparently without checking with Congress first, assuming CMS' Chief Actuary can "certify" that they save money*.

So now that we have a better handle on just what a "pilot" may be, what defines an "ACO?" According to the legislation, it still is a hospital-physician group entity that 1) has a legal structure so it can receive and disburse money, 2) has "sufficient numbers of primary care physicians," 3) is able to report on its outcomes, 4) "provides notice" to beneficiaries about the "pilot," 5) participates in a CMS hosted "best practices web site" 6) uses "patient centered processes of care" and 7) meets other criteria determined to be appropriate by the HHS Secretary (italics DMCB).

Readers can check out the good and the bad about ACOs for themselves, but to the DMCB, an awful lot of the ACO pilots' success will be riding on their ability to cement mutually beneficial physician-hospital relationships. The legislation apparently strives to achieve this by requiring 1) the right kind of financial arrangements (dollars that go to the docs) and 2) robust information technology (networked electronic records).

Which is why the DMCB, assuming The Reconciliation Act of 2010 survives, humbly offers up two suggestions about option of other criteria mentioned above. If it is the intent of Congress to pilot ACOs that have a good chance of success, the Secretary of HHS should give explicit preference to ACO pilots with either 1) a majority of their primary care physicians with meaningful (say, more than one year, 10% of their patients) experience in a DMAA defined disease management program, or 2) a majority of the primary care physicians with experience in a patient centered medical home demo that has been cited on the Patient Centered Primary Care Collaborative web site, or that possess NCQA PCMH recognition.

These two criteria are warranted because a track record of exposure to the 'systemness' of disease management (DM) or the PCMH can serve as a important sign that the ACO participants 'get it' when it comes to patient engagement and care management. While there may not be much in the way of research that has examined the links between DM/PCMH and ACO success, it stands to reason that having population-based care "seasoned" docs on board will increase the likelihood of achieving the outcomes and savings targets. These criteria will also increase the right kind of infrastructure, encourage experimentation with models of care that combine DM and the PCMH in usual care settings and explore that synergies between health information technology, physician incentives and state of the art population-based care management. As mentioned before, if done right, it will start where the MCCD left off.**

ACOs are the best part of this health reform package because they're one approach - if done right - that may actually "bend the curve" Even though it's tied up in Medicare's slow motion and often bumbling evaluation process as a pilot, so far, so good. The DMCB is hoping that this part of the bill remains intact in the sausage making yet to come.

* in legislative-ese, the quote is "would result in estimated spending that would be less than what spending would otherwise be estimate to be in the absence of such expansion"

** thankfully, the Senate bill's MCCD mandate appears to not be included in the Reconciliation Act

(There's lots more on Accountable Care Organizations here)

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