Proposed rule specifies ACO quality standards

The proposed rule for accountable care organizations (ACOs) from the Department of Health and Human Services (HHS) specifies how teams of doctors, hospitals, and other healthcare providers and suppliers will work together to coordinate and improve care for patients.

The rule specifies that to share in savings, ACOs must meet quality standards in five key areas:

• patient/caregiver care experiences;

• care coordination;

• patient safety;

• preventive health;

• at-risk population/frail elderly health.

The proposed rule also includes strong protections to ensure patients don't have their care choices limited by an ACO.

If ACOs save money by getting beneficiaries the right care at the right time — for example, by improving access to primary care so that patients can avoid a trip to the emergency department — the ACO can share in those savings with Medicare. ACOs that don't meet quality standards cannot share in program savings, and over time, those who don't generate savings can be held accountable.

The new program will be established on Jan. 1, 2012. Before the rule is finalized, CMS will review all comments from the public and might make changes to its proposals based on those comments.

HHS Secretary Kathleen Sebelius also announced that the agency will hold a series of open-door forums and listening sessions during the comment period to help the public understand what the Centers for Medicare & Medicaid Services (CMS), the agency administering the ACO program, is proposing to do and to ensure that the public understands how to participate in the formal comment process.

By focusing on the needs of patients and linking payment rewards to outcomes, this delivery system reform will help improve the health of individuals and communities while saving as much as $960 million over three years for the Medicare program, Sebelius said in a press conference.

CMS has worked closely with other federal agencies, including the Department of Health and Human Services Office of Inspector General (OIG), the Department of Justice (DOJ), the Federal Trade Commission (FTC), and Internal Revenue Service (IRS) to ensure that providers and suppliers have the clear and practical guidance they need to form ACOs without running afoul of the fraud and abuse, antitrust, and tax laws, Sebelius said. Concurrently with the publication of the proposed rule, the following documents have been issued: a joint CMS and OIG notice and solicitation of public comments on potential waivers of certain fraud and abuse laws in connection with the Medicare Shared Savings Program; a joint FTC and DOJ proposed antitrust policy statement; and an IRS notice requesting comments regarding the need for additional tax guidance for tax-exempt organizations, including tax-exempt hospitals, participating in the Medicare Shared Savings Program. The proposed rule and joint CMS/OIG notice are posted at http://www.regulations.gov/#!documentDetail;D=CMS-2010-0259-0425. A fact sheet is available at www.HealthCare.gov/news/factsheets/accountablecare03312011a.html. The Proposed Antitrust Policy Statement is posted at www.ftc.gov/opp/aco. The IRS Guidance and Solicitation of Comments are posted at http://www.irs.gov/pub/irs-drop/n-11-20.pdf.