ACO--Changes Fast and Furious

1
ACO--Changes Fast and Furious

• James G Hinsdale, MD, FACS
• President
• California Medical Association

2
Quick Chronology

• Elliott Fischer, Mark McClellan, Dartmouth
• Folded into the PPACA (March, 2010)
• Initially intended to be pilot
• CMS mandated to produce rules and regs
• Delayed regs emerged April, 2011
• Comment period about to end (June)

3
Grass Roots Poll

• Telephone conf with state presidents
• States California, New York, Texas, Illinois,
  Florida, Massachusetts, Colorado, Oregon, Idaho,
  Kansas
• Monolithic negative response
• Issues Downside risk Patient mobility
  performance standards (multiplicity)
• Rural doctors most opposed
• Interesting plan from Oregon Coordinated Care

4
Fears of Practicing Doctors

• Hospitals or Insurers will dominate them
• Loss of autonomy of care decisions
• Coercion into group practice
• Loss of income because of risk

5
Official Responses

• Organized Medicine----AMA--June 3, 2011
• 31 page document--detailed and exhaustive
• Criticism along many guidelines
• Plea to make this interim---not final
• CMA response added June 3, 2011

6
Major AMA Criticism

• Downside Risk
• Retrospective Patient Assignment
• Lack of Risk Adjustment
• Lack of control of costs of non-physicians
• Was supposed to be shared savings
• Patients can opt out--physicians at risk

7
AMA Criticisms

• CMS skimming 2 off the top
• 25 withhold for solvency
• 65 performance measures way too many
• Lack of risk adjustment during perform prd
• Problems with rural health clinics

8
AMA Suggestions

• Additional payment models (partial capitation)
• Patient education models
• Must reduce ACO accountability for patients who
  go where they like
• Reporting core plus 4-6 sets relevant to
  patient populations
• Must re-do fraud and abuse conflicts with various
  states (New Jersey, others)

9
California Comments

• California HMO models well entrenched
• ACO model inferior to successful HMO
• Rural doctors just as fearful as USA docs
• Fear of hospital domination

10
Who Embraces ACOs?

• In California, the insurance industry
• Foundations looking to get around corporate bar
• In Mass, groups, or would-be groups, that havent
  adopted HMO principles
• Oregon Coordinated Care Organizations
• Oregon resolution A-11 608--this HOD

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What to expect?

• Re-drawing of the regs
• Outcry to reduce the number of performance
  measures
• Dont insist on one model--a key factor
• Keep it piloted---phase it in
• May 17 --Pioneer Option from CMS
• Less savings, more pts, less groups, earlier
  start, same of quality measures