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ASA Responds to Accountable Care Organization Proposed Rule

Friday, June 03, 2011

Today, the American Society of Anesthesiologists responded to the Centers for Medicare and Medicaid Services (CMS) proposed rule on Accountable Care Organizations (ACOs). The comment letter from ASA President Mark A. Warner, M.D., states, “A decidedly chronic disease management focus, a primary care centered model and a lack of any attention to improving costly acute inpatient surgical management, combine to inhibit surgical specialists and anesthesiologists from actively participating in ACOs.”

In the 13-page letter, ASA outlines numerous ways CMS can improve the proposed rule.  In particular, the original proposed rule lacks a role for anesthesiologists within an ACO.  In response, for the first time the innovative Perioperative Surgical Home™ model of care was introduced to CMS by ASA.  In addition, ASA provides numerous other recommendations on changes that should be made to the proposed rule.

When the proposed rule was released, the ASA Ad Hoc Accountable Care Organization Task Force led by Norm Cohen, M.D., began analyzing the 429 page proposed rule.  This Task Force, in collaboration with ASA leadership and staff, developed ASA’s official comment letter to CMS.

All comments on the proposed rule must be submitted to CMS by June 6, 2011.  After the comment period ends, CMS will begin the process of developing a final rule.  The final rule is expected to be promulgated this Fall.  Once a final rule is released, ASA will offer guidance on the impact of the rule on the practice of anesthesiology as well as the role anesthesiologists can play in ACOs.

Click here to read the entire 13-page comment letter.

More information on ACOs is available here.

Below are some key pieces of the letter:
“A decidedly chronic disease management focus, a primary care centered model and a lack of any attention to improving costly acute inpatient surgical management, combine to inhibit surgical specialists and anesthesiologists from actively participating in ACOs.”

“While primary care physicians are proposed to serve as the core of an ACO, anesthesiologists are concerned that CMS does not envision much of a role for those, like anesthesiologists, involved in surgical or specialty care within an ACO.  ASA, however, believes that anesthesiologist engagement is critical to achieving the goals of reducing health care costs and improving quality of care.  To that end, ASA strongly promotes the  Perioperative Surgical Home™ model of care in order to achieve better value for beneficiaries through care coordination and process improvements led by anesthesiologists”

“While we acknowledge that CMS focused much of the ACO proposed rule on primary care, we recommend that CMS identify criteria to determine whether the ACO has an adequate number of specialists available to meet Medicare beneficiaries’ needs for patient-centered, acute care treatment and management.”

“ASA fears that including downside risk in the one-sided model will diminish interest in the ACO program, particularly in markets lacking a history of effective clinical integration.  ASA believes that CMS should propose another risk model that does not include any downside risk, and allow organizations to undertake downside risk at their own pace.”

“In addition, under the proposed rule, ACOs are provided an economic incentive to discourage beneficiaries from receiving care in teaching hospitals even when that may be the optimal setting for the patient.  This is because these hospitals receive direct graduate medical education (DGME),[1] indirect medical education (IME), and disproportionate share hospital (DSH) payments which means that a Medicare admission to a teaching hospital will incur higher Medicare payments than an admission to a nonteaching hospital.”

“Further, we recommend that CMS adopt a menu approach for quality measures reported by ACOs to afford flexibility to the ACO to determine which measures are most relevant to their practice, patients and Medicare beneficiaries.  Incorporating a one-size-fits-all approach could stifle innovation and unnecessarily increase compliance and health system costs.”

“While we encourage CMS to reduce the overall quality measurement reporting burden, ASA also recommends that CMS add measures to the menu that are relevant to the perioperative setting, including anesthesia-specific measures, to recognize care excellence or improvement in this setting.”

“We believe the ability of Medicare beneficiaries to seek care outside of an ACO coupled with the ACO notification requirements provide sufficient patient protections; however, if a beneficiary agrees to seek care and treatment in an ACO, part of that agreement should include sharing of necessary health care data with relevant and appropriate providers within that ACO.  All of the stakeholders in the Medicare system must participate and be accountable to achieve the goals of health system reform.”

“Anesthesiologists wish to continue our legacy of delivering high quality, patient-centered care and fervently want CMS to make the necessary changes to assure that the Medicare ACO program will both encourage and recognize our specialty’s contributions to achieving this goal.”

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