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ACO Participation: How Daunting?

April 6, 2011
by Mark Hagland
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One expert sees a fairly small number of providers developing ACOs

Among the many experts poring over the 429 pages of the proposed rule on accountable care organization (ACO) development that was published by the Department of Health and Human Services on March 31 was Mark Segal, Ph.D., who oversees governmental affairs at GE Healthcare IT. Segal says he believes that the net result of the complexity and challenges involved in ACO development, based on his interpretation of the proposed rule, is that a relatively small number of provider organizations will make the leap into ACO development. Segal spoke last week with HCI Editor-in-Chief Mark Hagland regarding the proposed rule. Below are excerpts from that interview.

Healthcare Informatics: What are your first impressions of the proposed rule?

Mark Segal, Ph.D.: I’d say it’s more or less as expected, based on reading the statute, and following various discussions. And Dr. Berwick [Donald M. Berwick, the administrator of the Center for Medicare and Medicaid Services (CMS)] made this point in a call-in session that CMS officials held, that they listened to a lot of comments they had received. It was surprising that they created a shared-risk as well as a shared-savings component. There had been talk, and MedPAC [the federal Medicare Payment Advisory Commission] had had discussions on this, but it was not widely expected to actually be in the rule.

Mark Segal, Ph.D.

HCI: Do you think that the proposed rule might have turned out slightly less advantageous to providers than some might have expected?

Segal: It’s a bit early to tell. I think everyone who’s looked at this has agreed that participating in an ACO would be a daunting task. I think we have to look carefully at the metrics involved. There are some very solid organizations looking at participating. And I spend a lot of time in the meaningful use area, and there’s a lot of complexity in the quality reporting in that area. And I think there will be an added complexity in terms of reporting quality data across multiple entities, in terms of ACOs.

I think it was widely expected that health IT would be very important in various forms, to the success of ACOs. But they talk about processes that promote evidence-based medicine, patient engagement, reporting of cost and quality, and coordination of care. And so as they talked about how to approach each of those areas, they said they had had the option of being prescriptive, or not so prescriptive. And they say they’ve chosen the latter, and that they’re asking applicants to describe how they do each of those. So for example, on evidence-based medicine, tell us, CMS, what your processes will be for evidence-based medicine and for coordination of care.

There might be many strategies in coordination of care, including telehealth, remote monitoring, or health information exchange. So it’s gratifying that they’re recognizing that there might be multiple strategies that could be pursued. They’re not being highly prescriptive, but they’re clearly sending multiple signals as to what they’re looking for.

And because quality reporting is so important, they’re planning to align the quality measures across the various Medicare programs, and as I’ve been reading this, they explicitly cite quality measures from meaningful use. And another thing they do is to stipulate that 50 percent of the primary care providers in an ACO have to be meaningful users by the second year of the program.

And so clearly, they recognize that in order to do what an ACO needs to do, first, you need to have adoption of an EMR, and Dr. Berwick was talking about that yesterday [March 31, the day of the release of the proposed rule]. And as well, the things involved in meaningful use, which from the start were to be coordinated with their plan for ACOs, have included similar themes, around quality of care, things like clinical decision support, which really are key to the evidence-based medicine aspect of ACOs; and themes like patient engagement and care coordination. So from the beginning of meaningful use, they’ve been trying to skate to where the puck is headed, and the puck is headed towards where ACOs are going. So to reduce provider burden, they’re aligning some of these requirements between meaningful use and ACOs.

HCI: Do you have a concern over the issue of patients having to OK data-sharing?

Segal: I think that’s certainly a very understandable concern. This is one where it sounds trite, but we’re going to have to wait and see. There’s been a general discussion about whether patients would need to be told that they’re assigned to an ACO. And I believe that they will need to be told that their provider is participating in an ACO.

HCI: Hopefully, patients wouldn’t have to agree to every single sharing of information, right?

Segal: I think it’s going to involve a blanket approval. And my personal expectation is that relatively few patients would opt out. If you think about when any of us go into a doctor or hospital, most people take the HIPAA acknowledgment and sign it. But certainly if significant numbers refused, that would pose a problem.

HCI: I think many organizations will be far more challenged by the IT and data reporting requirements than might be expected. What do you think?

Segal: I think the number of organizations that are initially going to be suited for this activity will be pretty small. But over time, with experience, things will get more standardized. And while it’s not formally a pilot, you’re looking at a program in its early stages of development.

What’s more, through CMS’s Innovation Center, other models might emerge. For example, models around partial capitation might evolve. With an ACO, you basically have to accept accountability for an entire population. But my sense is that CMS will provide a variety of possible models of risk. So you might have a program that emphasizes care for individuals with diabetes, for example. And through partial capitation, there might be a fair amount of risk involved for that specific population, so the risk might be made both deeper and at the same time narrower in scope.

HCI: What would your advice be for CIOs and others in informatics?

Segal: My advice would be to review the regulation, engage with the resources available in the industry, whether they be from associations or law firms holding webinars, for example. But ultimately, there is a big change management element here. You’re looking at creating new types of organizations. And recognize that there will be a need for consulting services and for change management consultations.

And it will be important to understand what is going on in your market, from the standpoint of private payers. In some states like Massachusetts, they’re planning to go fairly deeply into ACOs across the board. So, understand what kinds of ACO or ACO-like arrangements might be offered by private payers, and harmonize your operations, so you’re using similar efficiency and quality measures.

HCI: Do you have anything else to add?

Segal: This is really an important stop on the journey away from the traditional fee-for-service model and towards value-based payment and accountable care, but it’s only an early part of that journey.


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