Concerns Expressed Over Proposed ACO Rule

The College of Healthcare Information Management Executives (CHIME) has filed comments with the Centers for Medicare and Medicaid Services (CMS) to re-examine certain proposals contained in the Proposed Rulemaking for governing accountable care organizations (ACOs), which the trade group says will restrict the flow of information and create significant pressures on ACOs. Comments to the proposed rule are due to CMS by June 6.

CHIME’s comments cover five issues of the proposed rule: the ability of healthcare organizations to share data, and requirements that would create linkages between ACO rules, the meaningful use of electronic health records (EHRs), and health information exchange. In a telephone interview, Sharon Canner, CHIME’s director of advocacy, said that overall, saw a need for more flexibility to get as many physicians and hospitals as possible on board with the ACO model. By raising the bar on requirements too high, CMS risks not getting “enough takers to do the shared savings program, which is not going to accomplish the objective.”

Data Sharing. Chime expressed a concern over a proposed rule that gives patients enrolled in an ACO the ability to restrict access to their health information. ‘If beneficiary claims are withheld, the ACO’s ability to improve individual beneficiary health, as well as achieve the shared savings, could be compromised,” the comment said. CHIME recommends that “if a patient wishes to opt-out of claims sharing data he or she should be required to see a primary care physician (PCP) not affiliated with the ACO. Alternatively, the ACO-participating PCP could continue to see the patient, but that patient’s healthcare expenditures would not be taken into account in determining whether the ACO is eligible for shared savings or has incurred shared losses.”

One key to attracting enough patients to the ACO model is educating the patient, Canner says. “It depends on how it is communicated to the patient. If it is explained that the intent is to provide better quality of care, and having everybody on board with this and result is better care for you, there will be an understanding that this is important for their wellbeing to be a part of this.”

Meaningful Use Alignment. CHIME acknowledges that the proposed rules try to encourage the use of EHRs, but it takes issue with a requirement that stipulates that 50 percent of an ACO’s PCPs meet all MU standards by the beginning of the second year of the ACO’s agreement with CMS. “We think that is a high bar and we don’t think it is necessary to do that,” Canner says, while acknowledging the importance of aligning the programs. “While that is important, the stipulation that 50 percent of an ACO’s PCPs meet all meaningful use standards is too high a threshold.”

As an alternative, CHIME has proposed that CMS focus on outcomes, resulting from accountable care. “ACOs should be allowed to make decisions based on business requirements to achieve Care Coordination / Information System domain requirements, rather than prescribing MU objectives as necessary to be a participant in an ACO,” it says.

Shared Savings/Loss Calculation. CMS proposes to exclude EHR and other incentive payments made to eligible professionals from the ACO benchmark and actual expenditure calculations. CHIME agrees that incentive payments made to eligible professionals from the ACO benchmark and actual expenditure calculations. CHIME agrees that incentive programs received through other programs should have no bearing on shared savings targets ; it urges CMS to apply the same methodology to eligible hospitals. “To calculate shared savings without excluding EHR Incentive payments significantly undermines reasons for eligible hospitals to engage with CMS on this program,” according to the CHIME statement.

ACO Performance Measures. CHIME also expressed concern over the proposed use of 65 performance measures in the first year of the ACO program. “We think this is way too high,” says canner, adding that some of the measures don’t match up to meaningful use and other programs. “We want to make this work, but we don’t want to have make-work, requiring so much more from the provider that you lose sight of your main objectives,” she says.

As an alternative, CHIME recommends that CMS seek to align performance measures across similar or related programs and outline a more consistent approach for measuring quality improvement for the parts of other programs that overlap.

HIE and Other Technological Assumptions. Finally, CHIME urges CMS to scale back expectations for the use of health information exchange (HIE) to give healthcare organizations more time to enter HIE organizations and gain experience with the use of exchanged patient data in care delivery.

The ACO rules “are fairly prescriptive on technology,” Canner says. As an alternative, she says the decision on how to meet data collection and reporting requirements should lie with the ACOs, because it relates to their internal priorities. “Let them make the decision on what kind of technology they need to use.”