Significant changes to a proposed rule by the Centers for Medicare and Medicaid Services (CMS) that sets forth requirements and expectations for implementing the mandated Medicare Shared Savings program through Accountable Care Organizations (ACOs) are warranted, according to the American College of Radiology (ACR). In a June 3 letter written by ACR CEO Harvey L. Neiman, MD, FACR, and addressed to CMS Administrator Donald Berwick, MD, the ACR expresses multiple concerns regarding the assignment of beneficiaries, the tight linkage of quality measures to shared savings, the heavy emphasis on patient-centeredness, and other issues.
“The ACR is concerned that the basic premise of this proposed rule is flawed,” the letter says, noting that CMS “expects organizations to manage a population of patients that is unknown to them and beyond their control, making it extremely difficult to set up a successful model of integrated patient care” and that “the concept of tying the entire structure to the reporting of quality metrics with the goal of cutting costs while making patients the final arbiter” will not work. The ACR contends that shared savings seemingly cannot be realized by many groups that would like to participate in the ACO model.
“As evidenced by the Blue Cross and Blue Shield of Massachusetts (BCBS of MA) model quoted in the rule, a defined population is under a capitated fee-for-service agreement,” Neiman writes. “If the organization provides care within the cap, the savings realized are paid to that organization. Additionally, quality measures that are met will generate added savings. In this model, the two methods of achieving savings are not dependent upon each other. Conversely, in the ACO proposal, an organization would be required to participate in all 65 quality measures in addition to functioning within a budget in order to realize any savings. The return on investment for a contract such as this would be very questionable. One necessary remedy is for the patient satisfaction measures to be decoupled from the quality measures that show shared savings.”
On the beneficiaries front, the letter says, the ACR believes that inevitable patient attrition from ACOs renders the concept of establishing organizations “with a size anywhere near the minimum threshold of 5,000 beneficiaries, to say nothing of the economies of scale which would be lost in establishing an operation that small”, a risky one. Moreover, Neiman notes, the amount of investment required for such an endeavor, the level of risk involved, and a spate of stringent reporting requirements would make compliance difficult for small groups and the realization of any kind of shared services highly unlikely.
While the ACR is in favor of attributing patients to an ACO at the beginning of the process so that both the ACO and providers are aware of which patient’s care and costs are being tracked, it holds that the ability to characterize and attribute patients to a specific ACO will nonetheless be problematic without “clear guidance”. Its rationale: If a patient initially attributed to an ACO elects to leave that ACO for care, the latter should not be attributed to the ACO. “It is common for Medicare beneficiaries to live part of the year in one state and another part of the year in an entirely different part of the country,” but there remains the question of how these patients will be assigned, according to the letter.
Retrospective ACO attribution will pose challenge as well, the ACR alleges. “One of the major tenets of health care reform is eliminating fragmented care,” Neiman writes. “Therefore, we believe that CMS cannot design a system where patients choose fragmented care but make the ACOs accountable by misattribution. The rules of attribution should be made clear at the outset and remain consistent throughout the covered period.”
In terms of patient-centered care as it relates to diagnostic imaging, the ACR recommends that radiologists be assigned a pivotal role in assuring appropriate utilization of services within any given ACO. Using appropriateness criteria and other measures, Neiman points out in the letter, radiologists can substantially decrease inappropriate utilization, with cost savings to the ACO and decreased radiation dose to patients. Other recommendations stipulate that radiation dose management be one of the patient-centered quality criteria, as radiation dose management is complex, must be tailored to individual patients, and often requires case-by-case dose optimization. “Radiologists should be integral on the front end of coordinated care,” Neiman emphasizes. “For example, in a number of acute care episodes, radiologists can assist the primary care providers in determining the most efficient route to achieve a specific diagnosis. This process could streamline costs and potentially reduce inappropriate referrals to specialists for conditions that could be managed by the primary care providers.”
To complement front-end consultation, the association advocates in its comments the use of its appropriateness criteria as a valuable tool in helping primary care physicians to select the most appropriate study for the patient the first time around. Such a tool should, it believes, be augmented by access to a consulting radiologist to discuss further options.
The letter also expresses the ACR’s support for the maintenance of fee-for-service payments to individual providers under the ACA, and for the proposal that specialists be able to share in the savings at a .5% level. “Given the value-added elements that radiologists provide… radiology can definitely contribute to better quality and efficiencies in the ACOs,” it states. “The ACR…appreciates CMS’ proposal that specialists be allowed to participate in more than one ACO,” that the majority of specialists will be contracted partners with ACOs, and that only a small minority of radiologists will be employed by the ACO sponsor organization(s),” Neiman notes. However, he emphasizes, it will therefore be important for radiologists to be permitted to contract with hospitals in multiple rural areas, for example, so as to offer proper coverage of radiology services.
In terms of the ACR’s perspective on EHRs, the organization strongly believes that a robust electronic health record (EHR) is essential for an ACO because true accountable care cannot occur unless all providers caring for a patient have access to that individual’s medical information (including diagnostic imaging) in order to eliminate duplicative work, unnecessary utilization of services, and in the case of diagnostic imaging, unnecessary radiation exposure. “Physicians should incorporate EHRs into their practices, and there should be incentives for developing systems that allow ready transfer of electronic health information, including diagnostic images and reports, between institutions,” Neiman writes. “We also request that decision support systems…be tied into the EHRs.”
The letter further states that despite several mentions of small or physician group ACOs in the rule, the requirement that at least 50% of ACO PCPs be meaningful users appears to be well beyond the reach of any organization smaller than a large community hospital. Currently, the ACR contends, the proposal appears to be structured for health system-based integrated delivery systems. “It will be difficult for primary care physicians and other specialists to finance the IT, case management, and quality reporting requirements,” Neiman purports. “A special loan program could be made available for those practices that need to improve their information technology (IT) structure in order to integrate into an ACO system.”
He adds that while CMS’ current proposal that 65 quality measures be used by primary care is “commendable”, it leaves specialty physicians with no means of documenting their contributions to shared savings and “value-added”. The ACR considers it essential that quality measures reflect the realities of medical practice with respect to the deeply integrated relationship between primary care and specialty physicians. Just as significantly, CMS should consider that some measures will be needed that can be attributed to hospital practice, and some measures will be primarily for office-based practices, Neiman observes.
Additionally, the comments incorporate the ACR’s stance that hospital-based physicians should have metrics for value-based payments which reflect the unique role of hospital-based radiologists. In addition, ACO performance measures should ensure that physicians and hospitals have incentives for collaboration to achieve the same goals (for instance, implemented appropriateness criteria-based clinical decision support for imaging orders). Because some subspecialties currently lack measures, and a data collection and reporting system that addresses their scope of practice, reporting requirements should be phased in to ensure that physicians have the opportunity and resources to participate on a widespread basis, the ACR believes.
Participation by providers in data registries should also be incented, the letter specifies. Registries have the ability to monitor patient safety and outcomes in a variety of areas. In radiology, these include radiation dose, cancer diagnosis and surveillance, and cardiac diagnosis and vascular therapy.
