Adopted by the Massachusetts Medical Society in 2011 and the
American Medical Association in 2010.
1. Guiding Principle - The goal of an Accountable
Care Organization (ACO) is to increase access to care, improve the
quality of care and ensure the efficient delivery of care.
Within an ACO, a physician's primary ethical and professional
obligation is the well-being and safety of the patient.
2. ACO Governance - ACOs must be physician-led and
encourage an environment of collaboration among physicians.
ACOs must be physician-led to ensure that a physician's medical
decisions are not based on commercial interests but rather on
professional medical judgment that puts patients' interests
first.
Medical decisions should be made by physicians.
ACOs must be operationally structured and governed by an
appropriate number of physicians to ensure that medical decisions
are made by physicians (rather than lay entities) and place
patients' interests first. Physicians are the medical
professionals best qualified by training, education, and experience
to provide diagnosis and treatment of patients. Clinical decisions
must be made by the physician or physician-controlled entity.
The AMA supports true collaborative efforts between physicians,
hospitals and other qualified providers to form ACOs as long as the
governance of those arrangements ensure that physicians control
medical issues.
The ACO should be governed by a board of directors that is
elected by the ACO professionals. Any physician-entity [e.g.,
Independent Physician Association (IPA), Medical Group, etc.] that
contracts with, or is otherwise part of, the ACO should be
physician-controlled and governed by an elected board of
directors.
The ACO's physician leaders should be licensed in the state in
which the ACO operates and in the active practice of medicine in
the ACO's service area.
Where a hospital is part of an ACO, the governing board of the
ACO should be separate, and independent from the hospital governing
board.
3. Physician and patient participation in an ACO
should be voluntary. Patient participation in an ACO should
be voluntary rather than a mandatory assignment to an ACO by
Medicare. Any physician organization (including an
organization that bills on behalf of physicians under a single tax
identification number) or any other entity that creates an ACO must
obtain the written affirmative consent of each physician to
participate in the ACO. Physicians should not be required to
join an ACO as a condition of contracting with Medicare, Medicaid
or a private payer or being admitted to a hospital medical
staff.
4. The savings and revenues of an ACO should be
retained for patient care services and distributed to the ACO
participants.
5. Flexibility in patient referral and antitrust
laws. The federal and state anti-kickback and self-referral
laws and the federal Civil Monetary Penalties (CMP) statute (which
prohibits payments by hospitals to physicians to reduce or limit
care) should be sufficiently flexible to allow physicians to
collaborate with hospitals in forming ACOs without being employed
by the hospitals or ACOs. This is particularly important for
physicians in small- and medium-sized practices who may want to
remain independent but otherwise integrate and collaborate with
other physicians (i.e., so-called virtual integration) for purposes
of participating in the ACO. The ACA explicitly authorizes
the Secretary to waive requirements under the Civil Monetary
Penalties statute, the Anti-Kickback statute, and the Ethics in
Patient Referrals (Stark) law. The Secretary should establish
a full range of waivers and safe harbors that will enable
independent physicians to use existing or new organizational
structures to participate as ACOs. In addition, the Secretary
should work with the Federal Trade Commission to provide explicit
exceptions to the antitrust laws for ACO
participants. Physicians cannot completely transform their
practices only for their Medicare patients, and antitrust
enforcement could prevent them from creating clinical integration
structures involving their privately insured patients. These
waivers and safe harbors should be allowed where appropriate to
exist beyond the end of the initial agreement between the ACO and
CMS so that any new organizational structures that are created to
participate in the program do not suddenly become illegal simply
because the shared savings program does not continue.
6. Additional resources should be provided up-front
in order to encourage ACO development. CMS's Center for
Medicare and Medicaid Innovation (CMI) should provide grants to
physicians in order to finance up-front costs of creating an ACO.
ACO incentives must be aligned with the physician or physician
group's risks (e.g., start-up costs, systems investments, culture
changes, and financial uncertainty). Developing this capacity
for physicians practicing in rural communities and solo-small group
practices requires time and resources and the outcome is
unknown. Providing additional resources for the up-front
costs will encourage the development of ACOs since the "shared
savings" model only provides for potential savings at the back-end,
which may discourage the creation of ACOs (particularly among
independent physicians and in rural communities).
7. The ACO spending benchmark should be adjusted for
differences in geographic practice costs and risk adjusted for
individual patient risk factors.
The ACO spending benchmark, which will be based on historical
spending patterns in the ACO's service area and negotiated between
Medicare and the ACO, must be risk-adjusted in order to incentivize
physicians with sicker patients to participate in ACOs and
incentivize ACOs to accept and treat sicker patients, such as the
chronically ill.
The ACO benchmark should be risk-adjusted for the socioeconomic
and health status of the patients that are assigned to each ACO,
such as income/poverty level, insurance status prior to Medicare
enrollment, race, and ethnicity and health status. Studies
show that patients with these factors have experienced barriers to
care and are more costly and difficult to treat once they reach
Medicare eligibility.
The ACO benchmark must be adjusted for differences in geographic
practice costs, such as physician office expenses related to rent,
wages paid to office staff and nurses, hospital operating cost
factors (i.e., hospital wage index) and physician HIT costs.
The ACO benchmark should include a reasonable spending growth
rate based on the growth in physician and hospital practice
expenses as well as the patient socioeconomic and health status
factors.
In addition to the shared savings earned by ACOs, ACOs that
spend less than the national average per Medicare beneficiary
should be provided an additional bonus payment. Many
physicians and physician groups have worked hard over the years to
establish systems and practices to lower their costs below the
national per Medicare beneficiary expenditures. Accordingly,
these practices may not be able to achieve significant additional
shared savings to incentivize them to create or join ACOs. A
bonus payment for spending below the national average would
encourage these practices to create ACOs and continue to use
resources appropriately and efficiently.
8. The quality performance standards
required to be established by the Secretary must be consistent with
AMA policy regarding quality. The ACO quality reporting
program must meet the AMA principles for quality reporting,
including the use of nationally-accepted, physician
specialty-validated clinical measures developed by the
AMA-specialty society quality consortium; the inclusion of a
sufficient number of patients to produce statistically valid
quality information; appropriate attribution methodology; risk
adjustment; and the right for physicians to appeal inaccurate
quality reports and have them corrected. There must also be
timely notification and feedback provided to physicians regarding
the quality measures and results.
9. An ACO must be afforded procedural due
process with respect to the Secretary's discretion to terminate an
agreement with an ACO for failure to meet the quality performance
standards.
10. ACOs should be allowed to use different payment
models. While the ACO shared-savings program is limited to
the traditional Medicare fee-for-service reimbursement methodology,
the Secretary has discretion to establish ACO demonstration
projects.
ACOs must be given a variety of payment options and allowed to
simultaneously employ different payment methods, including
fee-for-service, capitation, partial capitation, medical homes,
care management fees, and shared savings. Any capitation
payments must be risk-adjusted.
11. The Consumer Assessment of Healthcare Providers and Systems
(CAHPS) Patient Satisfaction Survey should be used as a tool to
determine patient satisfaction and whether an ACO meets the
patient-centeredness criteria required by the ACO law.
12. Interoperable Health Information Technology and Electronic
Health Record Systems are key to the success of ACOs.
Medicare must ensure systems are interoperable to allow physicians
and institutions to effectively communicate and coordinate care and
report on quality.
13. If an ACO bears risk like a risk bearing organization, the
ACO must abide by the financial solvency standards pertaining to
risk-bearing organizations.
