Here are some of the key elements of Gov. Patrick's payment
reform bill, "An Act Improving the Quality of Health Care and
Controlling Costs by Reforming Health systems and Payments."
This summary is not a complete listing of the bill's provisions.
The full text of the bill is available in PDF format here.
- It defines the central characteristics of accountable care
organizations. ACOs must provide service coordination in accordance
with the principles of patient-centered medical homes, and provide
embedded primary care coordination and referral services.
ACOs are required to share financial risk and distribute savings,
and are responsible for meeting quality measures. ACOs must also be
competent in population health management, financial and contract
management, quality measurements, and provider and patient
communication. They must provide behavioral health services either
internally or by contractual arrangement.
- Physician participation in accountable care organizations is
voluntary. Primary care physicians may belong to only one ACO;
there is no such limit for specialists.
- The bill tries to curb the costly practice of defensive
medicine by mandating a 180-day cooling off period after an injured
patient signals an intention to file litigation. Certain
physician-patient communications required during that time period.
The bill also makes expressions of apology, regret, sympathy, and
other similar statements inadmissible as evidence in litigation.
The judgment interest for claims filed against ACOs is set at the
prevailing federal funds rate, which was 0.25% on 2/18/11. (The
general rate for malpractice claims is the federal funds rate plus
4 percentage points.)
- The bill doesn't directly set provider or insurer rates. But
the Division of Insurance has the right to reject insurance
contracts on basis of excessive premiums, if it finds insurer's
payments to providers were the cause of the high premiums.
- Everything would be overseen by a new coordinating council
consisting of 10 state agency leaders. It would consult regularly
with an 18-member advisory committee that includes payers,
hospitals, businesses, and four physician members. The bill gives
the advisory committee a voice on payment reform policy decisions,
but no direct vote.
- Quality measures for use in alternative payment methods would
be standardized across all health plans and must be
evidence-based.
- The bill directs the state to seek antitrust waivers from the
federal government so ACO providers can share risk and make
referrals more easily. It also expands state peer review
protections to ACOs.
- In several areas, the bill targets the differential in payments
among providers for similar services, explicitly setting a goal of
narrowing those differences.
- The bill does not require hospitals to be the only organizing
body for ACOs. It allows IPAs and other integrated health
organizations to form them and contract externally with hospitals,
if they meet the state's standards.
- The bill does not limit alternative payment methods to global
payment systems and allows for pilot programs on other
methodologies.
- It requires MassHealth, the Group Insurance Commission, the
Commonwealth Connector, and all other state-funded insurance
programs to implement ACOs and alternative payments by January
2014.
