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ACOS, Anesthesiologists and the “Surgical Home”

December 20, 2010

We have all encountered the abbreviation “ACO” often enough by now to realize that it stands for “Accountable Care Organization.” We do not know very much about these entities, however, despite the numerous articles we have read and presentations we have heard. Neither does CMS, the agency charged with launching the first ACO demonstration projects by 2012 under the Medicare shared savings program mandated by the Affordable Care Act. That is why CMS, in November, issued a Request for Information (RFI) on a number of issues such as quality measurement, patient attribution and payment models in ACOs.

The American Society of Anesthesiologists, which established a task force on ACOs at its Annual Meeting two months ago, responded in an 8-page letter to CMS that is an important guide to ASA’s initial concerns and desiderata. Some of those desiderata suggest subjects that should figure in anesthesia practices’ own strategic planning.

The Surgical or Perioperative Home

First, ASA for some time has been thinking about anesthesiologists’ role in managing the perioperative process in connection with potential global payments and integrated healthcare systems. When ACOs appeared in the Affordable Care Act, that thinking evolved toward the concept of a perioperative or “surgical home” comparable to the medical home model.  As explained on page 7 of ASA’s comment letter,

ASA strongly promotes the concept of a coordinated perioperative or surgical home model in order to achieve better value for beneficiaries through care coordination led by anesthesiologists. This model would be the counterpart to the medical home model and would be particularly effective in managing health care expenses. Approximately 60-70% of a traditional hospital’s expenses are associated with surgical and procedural (perioperative) care. The opportunity to reduce overall health care costs through improved coordination of surgical and procedural care is arguably better than the opportunity to reduce those care costs through a medical home model.

Specific ways in which the letter foresees that anesthesiologists can foster quality and cost savings include:

All of these activities are measurable.  If they are not already collecting their “value” data, anesthesia groups should consider tracking their contributions to or reducing unnecessary spending within their health systems, including endeavors that would come under one of the bullets above.  In this way they will prepare to implement the surgical home concept if and when they become part of an ACO or other integrated delivery system.  We recommend listening closely to ASA as it develops its internal understanding – and public awareness – of the surgical home.

For Which Patients Will the ACO and the Physician Be Accountable?

Another major issue in the shaping of Medicare ACOs and other shared-accountability organizations or payment models is the attribution of beneficiaries to ACOs, and the attribution of patients to individual providers, for purposes of calculating revenue shares.   

Whether attribution should be prospective or retrospective is still open for debate in health policy circles, but ASA, other medical associations and MedPAC (the Medicare Payment Advisory Commission, which advises Congress) are emphatic about the need to attribute patients to a particular ACO before the start of a performance period rather than at the end. They argue that both the physician and the patient should know, before the care is delivered, that the physician will be assigned accountability for the costs of all of the patient's care. "[F]or an ACO program to work well, beneficiaries will need to have greater engagement in their own care management (for example, medication adherence), according to MedPAC's comment letter responding to the ACO RFI.

To have greater engagement, patients will need to be informed up front that they are being assigned to a particular ACO.  “Without active patient support and participation, the ability of physicians to help patients improve their health, avoid unnecessary hospitalizations, and reduce the use of unnecessary and duplicative services is inherently limited,” stated ASA, urging CMS to hold an ACO accountable for the costs of care provided only to patients who voluntarily choose that ACO’s physicians to provide or manage their care.

Any and every global payment method that covers care provided by independently-practicing physicians will require a patient attribution system.  The discussions in the American College of Surgeons' coalition comment letter, as well as ASA’s and MedPAC’s letters regarding the attribution of patients to Medicare ACOs, will be a helpful start for anesthesia practices that want to understand the issues.

Performance Measurement

ACOs are not just about cost savings and provider payments, of course.  They are equally about the quality of care.  Thus a third fundamental question is what quality measures should Medicare or other ACOs use to determine performance?

There are four parts to ASA’s response:

  1.  “At least in the initial years of the ACO program, CMS should avoid requiring ACOs to collect and report quality measures beyond those that are already being required under other CMS programs, such as the Physician Quality Reporting System (PQRS), formerly the PQRI.”
  2. “ACOs should be allowed to report on a hybrid of nationally and locally focused quality measures related to their particular patient populations.”
  3. “ASA recommends that performance measures for anesthesiologists focus on improving safety and coordinating perioperative care. The following can be used to direct measure development: patient surgeries accomplished safely, surgeries accomplished under anesthesiologists’ direction, and perioperative care that includes evaluations from anesthesiologists and following of anesthetic plans.”
  4. The state of patient experience measurement, particularly for anesthesiology, is not sufficiently advanced to base incentive payments on patient satisfaction measures.

This is an area in which ASA and other organizations responding to the RFI came up with many different answers.  Anesthesiologists who negotiate performance measurement in the integrated health care delivery context should be aware that others, e.g., the American Association of Medical Colleges, the American College of Emergency Physicians, and various hospital associations, consider the dominant role of (1) patient satisfaction data and (2) National Quality Forum (NQF) endorsement of quality measures to be settled. 

MedPAC advised CMS that: 

ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. …  A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as:

In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. Patients may be more willing to stay assigned to the ACO if they know the provider’s payments are dependent on patients’ review of the quality of care provided.

Interestingly, AARP seemed to be channeling ASA in asking CMS to include "measures to assess important practices, such as care coordination and care transition, pain mitigation, infection avoidance, and the like."

Potential for ACOs to Violate Antitrust and Anti-Fraud Statutes

ACOs by their nature involve agreements that could "restrain trade," e.g. agreements on pricing between otherwise-competing providers, as well as incentives to reduce the amount of care delivered to Medicare beneficiaries.  The conflict between the Affordable Care Act Shared-Savings Program and the federal antitrust, physician self-referral, anti-kickback and Civil Monetary Penalty (CMP) statutes led CMS, the HHS Office of the Inspector General and the Federal Trade Commission to hold a joint workshop on the legal issues on October 5, 2010.  ASA and the surgical coalition urged CMS to create explicit safe harbors from the laws in question for ACOs.

The message to anesthesia practices here is very simple: do not participate in ACOs until the legal protections have been established.

CMS has reportedly delayed its release of initial ACO regulations, which were originally planned to be released this month, until mid-January while the agency reviews the many comment letters received in response to its RFI. We will continue our discussion of ACOs in an Alert after the proposed regulations appear in the Federal Register. 

With best wishes for a joyous holiday season,

Tony Mira
President and CEO