Accountable Care Organizations: Proposed Regulations Finally Released

Description

On Mar. 31, 2011, the Centers for Medicare and Medicaid Services issued its long-awaited proposed regulations regarding Accountable Care Organizations. Public comments must be submitted by June 6. The proposed rules provide for two risk models—the one-sided risk model and the two-sided risk model.

CMS estimates that approximately 75-150 organizations will participate as ACOs in the SSP with average start-up costs for each ACO of around $1.75 million dollars.

The rules include governance requirements, a requirement to submit the shared savings distribution system, new quality measures covering numerous categories including care coordination and patient safety. ACOs must meet a certain quality performance standard to receive shared savings.

The rule addresses antitrust, anti-kickback, civil monetary penalty, tax, and other laws, which may pose potential obstacles to aligning incentives and coordinating care among healthcare providers. The two-sided risk model raises potential state insurance/HMO regulatory issues that will be discussed.

Listen as our authoritative panel of health law attorneys and a healthcare consultant examines the new proposed ACOs regulations and offers best practices for navigating the potential obstacles when forming an ACO, now and in the future.

Outline

1. Proposed ACO regulations
   1. ACO governance and legal organization options
   2. Are 5000 minimum ACO beneficiaries sufficient? Is $1.75 million start-up cost realistic?
   3. Influence of MedPac’s recommendations on the proposed ACO regulations
   4. One-sided risk parameters
   5. Specific requirements regarding primary care physicians and other ACO physicians
   6. Medicare beneficiary's freedom of choice of physicians and other providers and controversial data-sharing patient opt-out right (ACO disclosure requirements and implications for ACO shared savings and two-sided risk model)
   7. Two-sided risk parameters and potential impact of state HMO/insurance law
2. Impact of other federal laws on ACOs and proposed waivers/exceptions
   1. Antitrust law
   2. Anti-kickback laws
   3. Civil monetary penalty law
   4. Tax law
3. Provider payment strategies
   1. Reimbursement continuum
   2. Payment models and developmental capabilities
   3. Bundled payments and episodes of care
   4. Combined bottom-line payment model
   5. Continuum of clinical care management
   6. Provider-payer care coordination focus

Benefits

The panel will review these and other key questions:

• What factors should healthcare providers consider when assessing participation in ACOs?
• What does the proposed rule require for ACOs to take responsibility for improving the quality of care while lowering costs in order to receive a share of the resulting savings?
• What are the legal obstacles that healthcare providers must overcome to participate in ACOs?

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