Reforming Accountable Care Organizations | The Regulatory Review

According to some experts, the traditional service pricing scheme used in these programs provides appropriate care to participants as the government pays the provider individually for each particular service offered. you can’t. As health insurance has become less affordable for taxpayers, the Biden administration has indicated that it will issue regulations aimed at reducing health care costs and increasing access. The government wants to partially achieve this by encouraging access to accountable care organizations (ACOs).

ACO is a prime example of what is known as a value-based care structure that is paid to a provider based on the patient’s health status of the services provided. ACO is a group of healthcare providers who voluntarily agree to coordinate the provision of quality care to Medicare and Medicaid recipients. ACO reduces healthcare costs by retaining a provider who is jointly responsible for the quality and cost of patient care.

The ACO model is believed to replace traditional service fee payment systems to reduce wasted spending and improve efficiency and fairness by tailoring payments to the needs of the population. In 2018, the Medicare and Medicaid Service Center (CMS) announced final rules encouraging ACOs to increase savings and accelerate the transition to a value-based care model. However, these models also require the ACO to reimburse the government if spending exceeds the target. As a result, many ACOs withdrew from CMS programs when costs increased.

In response, the CMS recently announced plans to change its Medicare-sponsored ACO program to improve system efficiency and promote health equity. The proposed changes are aimed at increasing participation, minimizing ACO’s accumulation of financial risk and equalizing access to healthcare services. The ACOREACH model, a pilot program starting January 1, 2023, will test stock enhancement capabilities to improve ACO’s delivery performance.

Despite the potential of ACOs to bridge the gap between CMS aspirations and reality, healthcare providers report that they are facing difficulties in implementing ACOs. Critics argue that ACOs impede the quality of care and cannot adequately reduce costs. However, some hope that with some adjustments, ACO may fulfill its promise of improving value-based care. While the ACO controversy continues, CMS seeks ways to save the ideal of accountable health care, reducing health care costs and improving quality of health care.

At this Saturday’s seminar, scholars will discuss whether ACOs are failing to meet their goals and how regulatory reform will improve performance.

• CMS needs to use empirical findings on ACO performance over the last decade to expand access to high-quality, low-cost healthcare, Todd Zigrang and Jessica Bailey-Wheaton of Health Capital Consultants said. Health lawyer.. In 2019, the US Department of Health and Human Services’ Directorate General of Inspection conducted a survey of 20 high-performance ACOs claimed by Zigrang and Bailey-Wheaton. It may be used by the CMS to guide future regulatory reforms. Based on the findings of the report, Zigrang and Bailey-Wheaton tell ACO that CMS will develop a robust primary care program that provides comprehensive, patient-centric care, reduces costs and improves quality of care. We conclude that we need to issue the new regulations we require.
• In a study published in American Journal of Managed CareNate C. Apathy of the University of Pennsylvania Perelman School of Medicine, Jay Holmgren of the University of California, San Francisco, and Rachel M. Werner of the Leonard Davis Health Economics Institute at the University of Pennsylvania say ACO aims to improve coordination between individuals. It’s a healthcare program that we’re talking about, but in many cases we can’t reach this goal. Apathy, Holmgren, and Werner have found that ACO participation increases health information exchange between providers, but this effect depends on the density of ACOs in a particular market. Apathy, Holmgren, and Werner conclude that policymakers need to more directly regulate data sharing to facilitate ACO coordination, as the US Department of Health and Human Services did earlier in 21 years. I am.^st The Century Cure Act is carried out by establishing a new center to coordinate and accelerate the development of medical products.
• In a study published in Group health managementBrandon W. Yan of the University of California, San Francisco School of Medicine and several co-authors distinguish between urban and rural ACO adoption rates. They argue that despite the steady growth of ACOs across the country, local organizations face challenges specific to formation and participation. Analysis of relevant market factors such as physician concentration, Medicare Advantage coverage, and commercial insurance coverage may show ACO presence in urban areas with low physician concentration and moderate Medicare Advantage participation You can see that the sex is high. The Yan team explains that national regulation must promote an ACO model that reduces barriers to the participation of local providers.
• According to Genevra F. Murray and Hector P. Rodriguez of Boston University School of Medicine, Medicaid ACO is currently working on integrating various social determinants of health, such as education and economic conditions, into the program. There are limited means of achieving the goal. Valerie Lewis, University of California, Berkeley, University of North Carolina, Gillings School of Public Health.In a study published in Health Affairs, They sampled 22 ACOs to assess the status of social welfare integration. Murray, Rodriguez, and Lewis have issued guidance on how CMS can use Medicaid dollars in non-healthcare programs, concluding that barriers to integration will continue unless they establish spending requirements for social needs. increase.
• In the article Milbank Quarterly, RTI International’s Stephanie M. Kissam and several co-authors evaluate the CMS’s State Innovation Model. It provided a total of $ 250 million to six states to test regulatory innovation aimed at moving to value-based care models such as ACO. According to the Kissam team, the state regulates the health system by providing oversight of health insurance companies, health professionals, and health insurance products. They found that several policy measures could affect state performance, including compulsory participation by state law, regulation of insurance companies requiring investment in primary care, and minimal spending on health information exchange systems. did. The Kissam team concludes that state regulatory measures that force healthcare professionals to reform existing practices will more effectively drive changes in health care systems than fiscal investment.
• According to Marilyn Uzdavines of Nova Southeastern College, health fraud and abuse laws are hampering the transition to value-based payment models such as ACO. Texas A & M Law Review.. Uzdavines could improve the cost and quality of medical care by changing the Stark law, a federal law that prohibits referrals to medical institutions when there is a financial relationship between the referral doctor and the medical institution. Suggests that there is. By clarifying key terms, modifying technical requirements that lead to inadvertent violations, and creating exceptions based on ACO’s new values, the reformed Stark Act counteracts legal barriers to improving healthcare delivery. Uzdavines argues that it may help.