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.
a. 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.
b. The ACO should be governed by a board of directors that
is elected by the ACO professionals. Any physician-entity that
contracts with, or is otherwise part of, the ACO should be
physician-controlled and governed by an elected board of
directors.
c. 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.
d. 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.
a. 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.
b. 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.
c. 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.
d. 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.
e. 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.
-- Passed the AMA House of Delegates, Nov. 9, 2010
