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ACO--Changes Fast and Furious

ACO--Changes Fast and Furious. James G Hinsdale, MD, FACS President California Medical Association. 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

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ACO--Changes Fast and Furious

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  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 ACO’s? • In California, the insurance industry • “Foundations” looking to get around corporate bar • In Mass, groups, or would-be groups, that haven’t adopted HMO principles • Oregon: “Coordinated Care Organizations” • Oregon resolution A-11 608--this HOD

  11. What to expect? • Re-drawing of the regs • Outcry to reduce the number of performance measures • Don’t 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

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