Accountable Care Organizations Take Form with Release of Final Rules Last week, the Centers for Medicare and Medicaid Services (CMS) announced final rules for the Medicare Shared Savings Program, known widely by its requirements to part of an Accountable Care Organization or ACO. The highly touted, much discussed ACO regulations have been on the radar of many in the healthcare world since passage of the Affordable Care Act in 2010. Then last spring, CMS issued a notice of proposed rule making that many, including CHIME, called untenable. CMS Administrator Dr. Donald Berwick said that public comments supplemented feedback received at dozens of informal listening sessions and what resulted was a more feasible and attractive on-ramp for a diverse set of providers and organizations to participate as ACOs.

In comments submitted in May 2011, CHIME agreed with Dr. Berwick and others at CMS who believe that ACOs represent the next evolution in healthcare delivery models meant to achieve (1) better care for individuals; (2) better health for populations; and (3) lower growth in expenditures. However, CHIME commented that further policy examination was needed in several key areas, specifically proposals regarding data sharing provisions, meaningful use (MU) alignment and assumptions about health information exchange capacities have the potential to undermine CMS goals and ACO effectiveness. Dr. Berwick was joined by Jonathan Blum, deputy administrator and director at the Center for Medicare, and Richard Gilfillan, M.D., acting director at the Center for Medicare and Medicaid Innovation (CMMI), in a stakeholder phone call introducing the final rule Thursday. During the call, several topics important to CHIME were addressed, including:

• a reduction of quality measures (from 65 down to 33);
• meaningful use of electronic health records will be a measure, but the 50-percent threshold of physicians achieving meaningful use is dropped; and
• flexible starting dates (April 1 and July 1) for each calendar year—which help those ACOs further develop more robust health information exchange capabilities if needed.

Advanced Payment Model Initiative to Help Small and Rural ACOs, CMS says A closely related initiative to the Shared Savings Program was also announced this Thursday, called the Advanced Payment Model initiative. Under the terms of the Advanced Payment Model, interested ACO participants could apply for funds to help overcome financial barriers to setting up an ACO. The Advance Payment Model was designed to support physician-owned and rural ACOs with upfront infrastructure investments. Under the terms of the model, these providers will receive payments in advance that will be recouped as they achieve savings, with three ways provider groups may receive these payments: (1) Upfront fixed payment; (2) Upfront payment based on the number of Medicare patients served; (3) Monthly payment based on the number of Medicare patients. Also mentioned were Pioneer ACOs—a pilot program designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. According to a fact sheet released by CMS (.pdf) in May, the Pioneer model will allow up to thirty provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Savings Program. Mr. Blum said the Pioneer and Advanced Payment initiatives were “all part of a bigger ‘menu of options’ to make care improvements and achieve lower costs,” that includes the Partnership for Patients, Bundled Payments, Comprehensive Primary Care Initiative and Advanced Primary Care Practice Demonstration.

CMS Updates Attestation FAQ with CQM Guidance CMS this week released guidance covering the finer points of attesting for meaningful use of electronic health records. Of particular note were updates to Frequently Asked Questions involving Clinical Quality Measures (CQMs). This has been the focus of several providers, including CHIME members, who recently spoke with CMS and ONC officials about the attestation process. According to CMS, they consider information to be "accurate and complete for CQMs" to the extent that it is identical to the output that was generated from certified EHR technology. “In other words,” the announcement said, “the hospital is only attesting that what was put in the attestation module is identical to the output generated by its certified EHR technology. Therefore, the numerator, denominator, and exclusion information for CQMs must be reported directly from information generated by certified EHR technology.”

The official guidance goes on to say, “CMS, through meaningful use, does not require any data validation. Eligible hospitals are not required to provide any additional information beyond what is generated from certified EHR technology in order to satisfy the requirement for submitting CQM information, even if the reported values include zeros. If a hospital has concerns about the accuracy of its output, the hospital can still attest but should work with its vendor and/or the Office of the National Coordinator for Health Information Technology to improve the accuracy of the individual product and/or the level of accuracy guaranteed by certification.

"CMS recommends that hospitals print out or save an electronic copy of the CQM report used at attestation from their certified EHR. The eligible hospital should retain this copy for its records so that the hospital can show its numbers in the event of an audit. Upon audit, this documentation will be used to validate that the hospital accurately attested and submitted CQMs."

For more information about the Medicare and Medicaid EHR Incentive Programs, please visit the CMS EHR website, and see the Frequently Asked Questions page for answers on various topic areas of the programs.”