Published 7/1/2011
Toya M. Sledd, MPH, MBA

Specialists have a role in Medicare shared savings programs

ACO model needs better definition of specialists’ role

Earlier this year, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule on accountable care organizations (ACOs), entities established under the Patient Protection and Affordable Care Act. The Federal Trade Commission and Department of Justice (FTC-DOJ) also released proposed guidelines on the antitrust enforcement policy regarding ACOs participating in the Medicare shared savings program.

AAOS response to CMS
On May 26, 2011, the American Association of Orthopaedic Surgeons (AAOS) formally submitted comments on these proposals. The comments were primarily drafted by the AAOS Health Care Systems Committee, chaired by Kevin J. Bozic, MD, MBA.

According to CMS, ACOs are intended to create incentives for healthcare providers to more closely collaborate in delivering care to patients across all care settings. ACOs will be rewarded based on their ability to lower healthcare costs while meeting performance standards on quality of care. Participation in an ACO by both patients and providers is voluntary, although patients receive no financial incentive for participation.

In particular, the AAOS provided input on payment provisions and asked for more clarity regarding the role of specialists in ACOs.

In its comments, the AAOS noted that “it is impossible to develop a ‘one-size-fits-all’ model.” It urged CMS to “clearly define the timetable for the distribution of shared savings and also to provide a transparent appeal system … in advance of any ACO beginning operations.” AAOS also proposed that “specialists should be allowed to develop payment distribution contracts within an ACO that support improved patient-level outcomes and cost reductions achieved by specialists.”

Although primary care providers have an important role in coordinating care, the AAOS noted that it is also important for CMS to maximize specialist participation in the management and development of ACOs. “Specialist physicians can and should play a vital role in ensuring the appropriate access to and use of specialty services by patients and their primary care providers,” commented the AAOS.

AAOS also offered the following suggestions for how specialists may add value in ACOs:

  • Defining appropriate use criteria for referral to specialists
  • Specifying appropriate indications for diagnostic and therapeutic interventions
  • Establishing performance measures related to specialty care
  • Developing innovative solutions to enhance communication between primary care and specialty providers

AAOS response to FTC-DOJ
With regard to the proposed regulation from the FTC-DOJ, the AAOS noted the importance of providing newly formed ACOs with appropriate antitrust guidance. AAOS also recognized, however, the importance of shielding ACOs from antitrust enforcement to the greatest extent possible to encourage better coordination and integration of healthcare services. The AAOS recommended that the FTC and the DOJ consider alternative definitions of antitrust violation beyond the thresholds described in the proposed rule.

“We will continue to monitor these issues and work with CMS to convey the perspective of our members,” said Dr. Bozic, “and to ensure that the AAOS will play a pivotal leadership role in defining the role of specialists in ACOs and other coordinated delivery systems.”

Toya M. Sledd, MPH, MBA, is the clinical quality improvement coordinator in the AAOS office of government relations. She can be reached at sledd@aaos.org

Where is the specialist in the ACO?
Although the ACO may seem similar to a patient-centered medical home with the primary care physician (PCP) as the most important player, an ACO will be required to provide care from specialists, including orthopaedic surgeons, and there are variations in how this can be achieved. The ACO itself is not mandated to include all specialists, but must manage the cost and quality of providing specialty care.

For integrated delivery systems interested in forming an ACO, there will be fewer changes. If healthcare providers organize into a Level 2 model (a multispecialty group plus a hospital), the specialist may need to join the group to continue providing service to the patients attributed to that ACO. For many specialists, the transition of their patients into an ACO may be invisible. Referral patterns, however, may be markedly affected. Although a specialist could have a relationship with several ACOs, the motivations to minimize cost and maximize quality may lead an ACO to identify “preferred” specialists. Preference could be expected for specialists who provide cost-effective and coordinated care through communication with their referring doctors.

Regardless of the level of integration of an ACO, coordination of care between the specialist, the PCP, and other care providers will be expected. This coordination is expected at multiple levels, from avoiding unnecessary duplication of labs or imaging to ensuring appropriate specialist referrals. Further, communication between specialists and the referring PCPs will increase in importance, both to avoid duplication and to guide the PCPs in conservative treatment of the patient. At each step, there will be an expectation to provide appropriate care in a cost-effective manner.

Successful implementation will require significant cultural changes from the motivations inherent in a fee-for-service model. Spontaneous implementation of change could be difficult, but reimbursement will likely be the driving force to bring coordinated care to fruition.

Excerpted from Accountable Care Organizations: A primer for orthopaedic surgeons, developed by the AAOS Health Care Systems Committee. Download a free copy of the primer from www.aaos.org/pracman

Additional Links:
AAOS letter to CMS (PDF)

AAOS letter to FTC-DOJ (PDF)