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Life Health > Health Insurance > Health Insurance

AHIP: If Providers Do What We Do, They Should Follow the Same Rules

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When accountable care organizations (ACOs) take on jobs that health plans have been handling, they should meet the same standards that health plans have to meet, according to America’s Health Insurance Plans (AHIP).

AHIP, Washington, and many other trade groups, professional societies, individuals and others have been responding to an ACO proposed rule released by the Centers for Medicare and Medicaid Services (CMS), an arm of the U.S. Department of Health and Human Services (HHS), in May.

CMS is implementing Section 30222 of the Patient Protection and Affordable Care Act of PPACA toolkit2010 (PPACA), which requires Medicare to test whether the ACO concept or other new care delivery and provider reimbursement strategies can help hold down Medicare costs while improving the quality of care.

CMS has proposed setting up a Medicare Shared Savings Program (MSSP) that would require hospitals, doctors and other providers to meet strict requirements when joining to form ACOs.

Any private insurers participating in an ACO also would have to meet strict requirements, such as a 25% cap on health insurer representation on an ACO’s governing body.

Providers have argued that the CMS MSSP rules are intimidating even for the large, well-funded, researcher-staffed group practices that have promoted the ACO concept.

The American Medical Association (AMA), Chicago, has submitted a comment calling for CMS to assign Medicare patients to ACOs based voluntary agreements, let physicians know which patients are in the ACO, and ease up on electronic health record use requirements.

The proposed rule would require a high percentage of primary care doctors in an ACO to be using electronic health records by the second year.

The AMA also is asking CMS to reduce the number of quality measures and reporting requirements ACO member health care providers would have to meet, and focus the quality requirements on the measures most relevant to a provider’s patient population.

Carmella Bocchino, an executive vice president at AHIP, and Joni Hong, a senior counsel at AHIP, say ACOs that are acting like health plans ought to be carefully regulated.

AHIP member companies have been meeting state insurance department financial requirements and

participating in large, complicated quality reporting programs run by the National Committee for Quality Assurance (NCQA), Washington, for years.

In the 1990s, Bocchino and Hong write, provider-sponsored organizations and physician-hospital organizations tried to take on varying degrees of financial risk for managing patients’ care.

“These arrangements did not result in the highly anticipated improvements in quality and efficiency, and in fact led to the closure or bankruptcy of 147 physician organizations serving 4.1 million patients in California between 1998 and 2002,” the AHIP representatives write. “The experience resulted in confusion, discontinuity of care and market disruption for consumers.”

To manage risk and care successfully, provider organizations need to learn from health plans, Bocchino and Hong say.

The 25% cap of insurer participation in ACO governing bodies is an example of an arbitrary standard, the AHIP reps say.

“CMS’ focus should be ensuring that an ACO has a demonstrated ability to treat individuals, improve population health, and create programs and perform outreach to reduce unnecessary care,” the AHIP reps say. “To that end, ACOs should have the maximum amount of flexibility to create governing bodies that best meet their individual needs and help them achieve the intended goals.”

If ACOs meet assume the kinds of financial risk a health plan meets, they should meet the same standards comparable health plans would have to meet, the AHIP reps say.

“These standards include financial requirements (e.g., capital, reserve and solvency requirements); network requirements (e.g., ensuring access to adequate numbers and types of providers); filing, reporting and disclosure requirements; and quality improvement requirements, including accreditation standards and other consumer protection standards,” the AHIP reps say. “If ACOs are not subject to the same standards, consumers receiving care from an ACO may have less access to care, receive care of lesser quality, be faced with increased costs, and/or be more vulnerable to discontinuation of coverage if unforeseen events occur, such as a flu pandemic or similar disaster impacting the health care system.”

Other ACO coverage from National Underwriter Life & Health:


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