Becker's ASC Review: 50 Things to Know About the Proposed ACO Regulations

1. ACO Participants cannot participate in other Medicare shared savings programs
2. An ACO may include the following types of providers: ACO professionals, Networks of individuals practices, Partnership/joint venture, Hospital employing ACO professionals, others as determined by HHS
3. The regulations provide for a once-a-year start date of Jan. 1
4. ACO agreements will be for three years with one-year performance measurement periods
5. Medicare fee-for-service beneficiaries will be retroactively assigned to ACOs based on primary care utilization during a performance year
6. Beneficiaries will not be assigned to more than one ACO
7. Beneficiaries will not receive advance notice of their ACO assignment
8. CMS expects 5 million Medicare beneficiaries to receive care from providers participating in a shared savings program
9. An ACO must have at least 5,000 beneficiaries
10. The board of an ACO must include some Medicare beneficiaries
11. The ACO board must include representation from all ACO participants
12. No more than 25 percent of board seats can be held by non-ACO participants such as entrepreneurial companies
13. The proposed regulations do not require an ACO to become a separate legal entity with a separate Tax Identification Number
14. The ACO can enter into a one-sided or two-sided shared savings agreement
15. Cost targets, from which savings will be calculated, will be based on retrospective review of aggregate beneficiary-level data for the assigned population
16. CMS will set spending benchmarks based on three years of data
17. Generally there is no savings shared or costs to be borne unless savings are at least 2 percent above or below the benchmark
18. The ACO entity is responsible for distributing savings to participating entities
19. ACOs will be subject to a withhold of shared savings to offset possible future losses
20. To be eligible to receive shared savings, the ACO must also meet certain quality standards
21. An ACO must develop a process to promote evidence-based medicine, patient engagement and coordination of care
22. ACOs must have a patient survey tool in place
23. ACOs must have a process for evaluation the health needs of the population it serves
24. ACOs must have systems to identify high risk beneficiaries and develop individual care plans for target populations
25. An ACO must report and maintain a database of all ACO participants and their National Provider Identifiers
26. ACOs must have a compliance plan and conflicts of interest policies and means to screen ACO participants
27. ACOs must get approval for any changes in ACO participants (i.e., providers) during the three-year contract period
28. Where an ACO's structure or participants changes during a term, CMS has five different ways it may respond
29. Primary care providers may only participate in one ACO
30. Physicians eligible for primary care provider status include internal medicine, general practice, family practice and geriatric medicine specialists
31. At least 50 percent of an ACO's primary care physicians must be meaningful EHR users as defined by the HITECH Act and subsequent Medicare regulations
32. Each ACO will have significant public reporting requirements in a standardized format
33. ACOs must have a data-use agreement with CMS
34. CMS will share aggregate population data regarding the ACO's population several times per year
35. CMS may monitor to ensure they are not avoiding at-risk beneficiaries or distributing unapproved marketing materials in addition to a whole range of other issues
36. ACOs must agree to be open wholly to audits
37. The regulations set forth 16 grounds for termination of an ACO's shared savings agreement with CMS
38. There are several concepts which are not subject to appeal by an ACO if it is terminated from the program by CMS
39. CMS can change the program during a contract term, but can't change the rules regarding the eligibility requirements of an ACO, calculation of the shared savings rate and beneficiary assignment
40. CMS and the OIG have proposed waivers with regard to Civil Monetary Penalty, Antikickback and Stark laws solely as to relationships wholly related to an ACO
41. Preliminary guidance from IRS available
42. Preliminary guidance from antitrust agencies available
43. The core concepts of the ACO program are to achieve better care for individuals, better health for populations and lower growth for Medicare expenditures
44. Comments on the proposed rule will be accepted for 60 days after the proposed rule is published in the Federal Register (expected April 7, 2011, so until June 6, 2011)
45. The ACO program is scheduled to go into effect on Jan. 1, 2012
46. Will require massive bureaucracy
47. Regulations are idealistic
48. Regulations limit business involvement
49. Regulations require beneficiary representation in ACO governance
50. Regulations favor PCPs

Source: Becker's ASC Review
Source URL: http://www.beckersasc.com/news-analysis/50-things-to-know-ab...

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