Dr. Goertz said the AAFP will file public comments on the proposed regulation urging changes to make it more attractive to smaller practices. In the meantime, he advised family physicians not to rush into any ACO deals. Family physicians are in a good bargaining position and should try to avoid making commitments to other organizations before they have a clear sense of the final regulation from the CMS.
When it comes time to make those agreements, physicians must be clear on the details of risk sharing and payments to individual physicians. "Don’t undervalue yourself in terms of the potential of the ACO," he advised.
Officials at the American Medical Association also have voiced some concerns about the investments that physicians, especially those in small practices, would need to make in order to become part of an ACO. Potential investment might include an electronic health record, hiring nurse care managers to assist in patient education and self-support, or adding currently unreimbursed services such as e-mail communication with patients and other physicians.
The AMA has recommended that the CMS create loan- and technical-assistance programs to help small physician practices in becoming ACOs. Since commercial lenders might be reluctant to grant lines of credit, given the uncertainty and confusion that surround health care payments, the AMA suggested that the CMS educate lenders on the new revenue streams associated with ACOs. CMS also could create a loan guarantee program to make it easier for small physician practices and IPAs to get financing from commercial lenders. Or, the AMA suggested, the CMS could make grants to nonprofit commercial organizations that could provide grants, loans, and technical assistance.
One area in which physicians may need to make investments is in health information technology. Jonathan Blum, director of the Center for Medicare Management, said the ACO proposal is closely aligned with the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the electronic health record incentive programs. Coordinating the ACO quality measures with those in the EHR incentive programs reduces the burden on physicians and hospitals that are submitting data through the various programs, Mr. Blum said. It also offers the potential for physicians to offset some of their technology costs through the bonus payments they can earn by achieving meaningful use of their EHRs. (Click here to view a video interview with Dr. Blum).
The move to ACOs will be a major shift, said Dr. Paul Grundy, director of health care transformation for IBM and president of the Patient-Centered Primary Care Collaborative. "You’ve got a $2.7 trillion stream going in the wrong direction," he said. "That’s a huge river to overcome."
But despite the financial and cultural barriers that have prevented these types of shifts from occurring in the past, Dr. Grundy said the medical community is ready to make a change toward the patient-centered medical home concept and ACOs.
Many purchasers of health care, including Fortune 100 companies and the federal government, are already supporting the concept of the medical home and physicians who have made the switch love it, he said. "I think it’s really clear that this is where we’re going and where we have to go."
The trend is being driven by more than just the provisions in the Affordable Care Act, he said. The escalating cost of health care is pushing businesses and other health care purchasers to look for alternatives to keep costs down. At the same time, there are finally data to show how patients are being managed and what types of care are cost effective. Additionally, younger consumers want to access health care the same way they do their banking and shopping. "For them to be told by a practice that they can’t access their laboratory data online, they’ll just keep looking until they find someone who can," Dr. Grundy said.
Another player in the ACO field is the NCQA. The not-for-profit organization offers recognition programs for physicians, hospitals, and health plans in a number of areas. Starting this summer, the organization plans to unveil its standards for ACO accreditation. The first ACOs to go through the program could receive accreditation in 2012, according to Raena Grant Akin-Deko, assistant vice president for development at the NCQA.
The standards could be a "road map" for organizations to begin to build the capabilities to become an ACO, she said. "What we’ve done through these standards can help people understand what the important capabilities are and give them some direction about what are the things that they should be thinking about."