Mary Ellen Schneider

Federal officials are pouring a $1 billion into a new initiative aimed at reducing hospital readmissions and preventable injuries.

The “Partnership for Patients” brings together physicians, nurses, hospitals, patient advocates, insurers, and employers for a 3-year project that will help spread the lessons of successful quality improvement initiatives across the country and provide tools for health care providers.

Many hospitals have already had success in reducing readmissions or nearly eliminating hospital-acquired infections, but those initiatives haven't been adopted widely enough, Health and Human Services Secretary Kathleen Sebelius said at a press conference to launch the Partnership for Patients. “The challenge is how to figure out how to make these models spread and accelerate this care improvement,” she said.

The goal of the program is to reduce preventable hospital-acquired conditions by 40% compared to 2010 rates by the end of 2013. Officials are also seeking to lower hospital readmissions within 30 days of discharge by 20% compared to 2010. HHS officials estimate that the quality initiative will save 60,000 lives and up to $35 billion in health care costs, including up to $10 billion for Medicare alone.

The $1 billion investment of federal funds comes from the Affordable Care Act. HHS officials said they were making $500 million available right away through the Community-Based Care Transitions Program to support efforts to improve care transitions between hospitals and physicians in the community.

Hospitals and community-based organizations that team up to provide transition services can submit applications to HHS for funding. An additional $500 million will come from the CMS Innovation Center to fund demonstration projects aimed at reducing hospital-acquired conditions.

Under the Partnership for Patients, HHS officials are asking hospitals to focus on nine types of adverse events including drug reactions, pressure ulcers, childbirth complications, and surgical site infections. HHS officials also plan to recruit a group of “pioneer” hospitals that would seek to improve care for all forms of harm and complications, said Dr. Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. Dr. Berwick said these hospitals would go beyond the list of nine conditions and seek to transform themselves into “safer, high-reliability organizations.”

“By assembling this partnership and committing to these ambitious goals, we're sending a clear message that we can no longer accept a health care system in which only some Americans get the best possible care,” Ms. Sebelius said.

Federal officials are pouring a $1 billion into a new initiative aimed at reducing hospital readmissions and preventable injuries.

The “Partnership for Patients” brings together physicians, nurses, hospitals, patient advocates, insurers, and employers for a 3-year project that will help spread the lessons of successful quality improvement initiatives across the country and provide tools for health care providers.

Many hospitals have already had success in reducing readmissions or nearly eliminating hospital-acquired infections, but those initiatives haven't been adopted widely enough, Health and Human Services Secretary Kathleen Sebelius said at a press conference to launch the Partnership for Patients. “The challenge is how to figure out how to make these models spread and accelerate this care improvement,” she said.

The goal of the program is to reduce preventable hospital-acquired conditions by 40% compared to 2010 rates by the end of 2013. Officials are also seeking to lower hospital readmissions within 30 days of discharge by 20% compared to 2010. HHS officials estimate that the quality initiative will save 60,000 lives and up to $35 billion in health care costs, including up to $10 billion for Medicare alone.

The $1 billion investment of federal funds comes from the Affordable Care Act. HHS officials said they were making $500 million available right away through the Community-Based Care Transitions Program to support efforts to improve care transitions between hospitals and physicians in the community.

Hospitals and community-based organizations that team up to provide transition services can submit applications to HHS for funding. An additional $500 million will come from the CMS Innovation Center to fund demonstration projects aimed at reducing hospital-acquired conditions.

Under the Partnership for Patients, HHS officials are asking hospitals to focus on nine types of adverse events including drug reactions, pressure ulcers, childbirth complications, and surgical site infections. HHS officials also plan to recruit a group of “pioneer” hospitals that would seek to improve care for all forms of harm and complications, said Dr. Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. Dr. Berwick said these hospitals would go beyond the list of nine conditions and seek to transform themselves into “safer, high-reliability organizations.”

“By assembling this partnership and committing to these ambitious goals, we're sending a clear message that we can no longer accept a health care system in which only some Americans get the best possible care,” Ms. Sebelius said.

Federal officials are pouring a $1 billion into a new initiative aimed at reducing hospital readmissions and preventable injuries.

The “Partnership for Patients” brings together physicians, nurses, hospitals, patient advocates, insurers, and employers for a 3-year project that will help spread the lessons of successful quality improvement initiatives across the country and provide tools for health care providers.

Many hospitals have already had success in reducing readmissions or nearly eliminating hospital-acquired infections, but those initiatives haven't been adopted widely enough, Health and Human Services Secretary Kathleen Sebelius said at a press conference to launch the Partnership for Patients. “The challenge is how to figure out how to make these models spread and accelerate this care improvement,” she said.

The goal of the program is to reduce preventable hospital-acquired conditions by 40% compared to 2010 rates by the end of 2013. Officials are also seeking to lower hospital readmissions within 30 days of discharge by 20% compared to 2010. HHS officials estimate that the quality initiative will save 60,000 lives and up to $35 billion in health care costs, including up to $10 billion for Medicare alone.

The $1 billion investment of federal funds comes from the Affordable Care Act. HHS officials said they were making $500 million available right away through the Community-Based Care Transitions Program to support efforts to improve care transitions between hospitals and physicians in the community.

Hospitals and community-based organizations that team up to provide transition services can submit applications to HHS for funding. An additional $500 million will come from the CMS Innovation Center to fund demonstration projects aimed at reducing hospital-acquired conditions.

Under the Partnership for Patients, HHS officials are asking hospitals to focus on nine types of adverse events including drug reactions, pressure ulcers, childbirth complications, and surgical site infections. HHS officials also plan to recruit a group of “pioneer” hospitals that would seek to improve care for all forms of harm and complications, said Dr. Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. Dr. Berwick said these hospitals would go beyond the list of nine conditions and seek to transform themselves into “safer, high-reliability organizations.”

“By assembling this partnership and committing to these ambitious goals, we're sending a clear message that we can no longer accept a health care system in which only some Americans get the best possible care,” Ms. Sebelius said.

After months of deliberation, officials at the Centers for Medicare and Medicaid Services released a proposed rule outlining how physicians, hospitals, and long-term care facilities can work together to form accountable care organizations and share in the savings they achieve for Medicare.

The voluntary program was created under the Affordable Care Act and will begin in Jan. 2012. Under the proposal, accountable care organizations (ACOs) could include physicians in group practice, networks of individual practices, hospitals that employ physicians, and partnerships among these entities, as well as other providers. The idea is for ACOs to be a partnership among a range of physicians, including specialists and primary care providers. However, only primary care providers will be able to form an ACO, according to CMS.

According to the proposed rule, providers in the ACO would continue to receive their regular fee-for-service payments under Medicare, but they could also qualify for additional payment if their care resulted in savings to the program. The proposed framework requires that ACOs meet certain quality standards and demonstrate that they have reduced costs in order to be eligible to share in any savings. The proposal outlines 65 quality measures in five quality domains: patient experience, care coordination, patient safety, preventive health, and care of at-risk and frail elderly populations.

“ACOs aren't just a new way to pay for care; they're a new model for the organization and delivery of the care under Medicare,” Dr. Donald Berwick, CMS administrator, said during a press conference to announce the proposed rule.

Dr. Berwick said he doesn't know how many ACOs will form under the program, but that the level of interest is “enormous.”

Since the Affordable Care Act was passed last year, the health care community has been buzzing about how ACOs might be structured and if they could succeed in reducing health care costs. Integrated care organizations like Geisinger Health System in Danville, Pa., are considered to have a leg up because their hospital and outpatient care is already coordinated.

But Dr. Berwick said that the proposal allows for ACOs at various levels of development to participate. For example, less developed ACOs can choose to receive only shared savings for 2 years before assuming risk. More mature organizations can assume risk immediately but be eligible for greater levels of shared savings.

CMS officials estimate that the program could result in as much as $960 million in Medicare savings over 3 years.

ACOs will not be set up like HMOs. Medicare beneficiaries will continue to be able to see their choice of providers under fee-for-service Medicare. Providers will be the ones that enroll in ACOs and must notify patients that they are receiving care within an ACO.

In addition to the ACO proposed rule, the Department of Justice and the Federal Trade Commission have issued guidance on how physicians and hospitals that form an ACO can steer clear of antitrust laws. Officials at the CMS and the Office of the Inspector General have also issued a notice on potential waivers that could be granted in connection with the shared savings program, and the Internal Revenue Service has issued new guidance for tax-exempt hospitals seeking to participate in the program.

The CMS will be accepting comments on the proposed rule. The agency also plans a series of open-door forums and listening sessions to explain the proposal and to get feedback from the public.

After months of deliberation, officials at the Centers for Medicare and Medicaid Services released a proposed rule outlining how physicians, hospitals, and long-term care facilities can work together to form accountable care organizations and share in the savings they achieve for Medicare.

The voluntary program was created under the Affordable Care Act and will begin in Jan. 2012. Under the proposal, accountable care organizations (ACOs) could include physicians in group practice, networks of individual practices, hospitals that employ physicians, and partnerships among these entities, as well as other providers. The idea is for ACOs to be a partnership among a range of physicians, including specialists and primary care providers. However, only primary care providers will be able to form an ACO, according to CMS.

According to the proposed rule, providers in the ACO would continue to receive their regular fee-for-service payments under Medicare, but they could also qualify for additional payment if their care resulted in savings to the program. The proposed framework requires that ACOs meet certain quality standards and demonstrate that they have reduced costs in order to be eligible to share in any savings. The proposal outlines 65 quality measures in five quality domains: patient experience, care coordination, patient safety, preventive health, and care of at-risk and frail elderly populations.

“ACOs aren't just a new way to pay for care; they're a new model for the organization and delivery of the care under Medicare,” Dr. Donald Berwick, CMS administrator, said during a press conference to announce the proposed rule.

Dr. Berwick said he doesn't know how many ACOs will form under the program, but that the level of interest is “enormous.”

Since the Affordable Care Act was passed last year, the health care community has been buzzing about how ACOs might be structured and if they could succeed in reducing health care costs. Integrated care organizations like Geisinger Health System in Danville, Pa., are considered to have a leg up because their hospital and outpatient care is already coordinated.

But Dr. Berwick said that the proposal allows for ACOs at various levels of development to participate. For example, less developed ACOs can choose to receive only shared savings for 2 years before assuming risk. More mature organizations can assume risk immediately but be eligible for greater levels of shared savings.

CMS officials estimate that the program could result in as much as $960 million in Medicare savings over 3 years.

ACOs will not be set up like HMOs. Medicare beneficiaries will continue to be able to see their choice of providers under fee-for-service Medicare. Providers will be the ones that enroll in ACOs and must notify patients that they are receiving care within an ACO.

In addition to the ACO proposed rule, the Department of Justice and the Federal Trade Commission have issued guidance on how physicians and hospitals that form an ACO can steer clear of antitrust laws. Officials at the CMS and the Office of the Inspector General have also issued a notice on potential waivers that could be granted in connection with the shared savings program, and the Internal Revenue Service has issued new guidance for tax-exempt hospitals seeking to participate in the program.

The CMS will be accepting comments on the proposed rule. The agency also plans a series of open-door forums and listening sessions to explain the proposal and to get feedback from the public.

After months of deliberation, officials at the Centers for Medicare and Medicaid Services released a proposed rule outlining how physicians, hospitals, and long-term care facilities can work together to form accountable care organizations and share in the savings they achieve for Medicare.

The voluntary program was created under the Affordable Care Act and will begin in Jan. 2012. Under the proposal, accountable care organizations (ACOs) could include physicians in group practice, networks of individual practices, hospitals that employ physicians, and partnerships among these entities, as well as other providers. The idea is for ACOs to be a partnership among a range of physicians, including specialists and primary care providers. However, only primary care providers will be able to form an ACO, according to CMS.

According to the proposed rule, providers in the ACO would continue to receive their regular fee-for-service payments under Medicare, but they could also qualify for additional payment if their care resulted in savings to the program. The proposed framework requires that ACOs meet certain quality standards and demonstrate that they have reduced costs in order to be eligible to share in any savings. The proposal outlines 65 quality measures in five quality domains: patient experience, care coordination, patient safety, preventive health, and care of at-risk and frail elderly populations.

“ACOs aren't just a new way to pay for care; they're a new model for the organization and delivery of the care under Medicare,” Dr. Donald Berwick, CMS administrator, said during a press conference to announce the proposed rule.

Dr. Berwick said he doesn't know how many ACOs will form under the program, but that the level of interest is “enormous.”

Since the Affordable Care Act was passed last year, the health care community has been buzzing about how ACOs might be structured and if they could succeed in reducing health care costs. Integrated care organizations like Geisinger Health System in Danville, Pa., are considered to have a leg up because their hospital and outpatient care is already coordinated.

But Dr. Berwick said that the proposal allows for ACOs at various levels of development to participate. For example, less developed ACOs can choose to receive only shared savings for 2 years before assuming risk. More mature organizations can assume risk immediately but be eligible for greater levels of shared savings.

CMS officials estimate that the program could result in as much as $960 million in Medicare savings over 3 years.

ACOs will not be set up like HMOs. Medicare beneficiaries will continue to be able to see their choice of providers under fee-for-service Medicare. Providers will be the ones that enroll in ACOs and must notify patients that they are receiving care within an ACO.

In addition to the ACO proposed rule, the Department of Justice and the Federal Trade Commission have issued guidance on how physicians and hospitals that form an ACO can steer clear of antitrust laws. Officials at the CMS and the Office of the Inspector General have also issued a notice on potential waivers that could be granted in connection with the shared savings program, and the Internal Revenue Service has issued new guidance for tax-exempt hospitals seeking to participate in the program.

The CMS will be accepting comments on the proposed rule. The agency also plans a series of open-door forums and listening sessions to explain the proposal and to get feedback from the public.

The medical model of “the more you do, the more you make” is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.

Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).

HealthCare Partners' physicians in California have been working in the global capitation market for many years and Dr. Chin said this experience will help them transition to being an ACO.

“We have had the experience of improving outcomes and reducing costs, improving patient satisfaction, improving the patient experience in our model,” Dr. Chin said. “Some of the common goals of the ACO are things that we are doing today.”

This year is likely to be a “learning year” for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records. Without that investment in technology, it's nearly impossible to become efficient and improve quality because paper charts are intractable to analysis, according to Dr. Chin.

But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.

ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.

Officials at the Centers for Medicare and Medicaid Services released a proposed regulation on Mar. 31 outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers.

An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.

Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings.

The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.

The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.

More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-sided risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-sided risk model.

Physicians' groups see pluses and minuses in the government's vision for ACOs.

The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn't provide much incentive for small- and medium-size practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.

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.

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.”

The NCQA recently concluded testing of its standards with 10 organizations that represent IPAs, multispecialty practice groups, and integrated delivery systems. One issue that came up during the testing is the importance of leadership within the ACO.

“We can define structural features that are important for [ACOs], but I think you cannot underestimate the importance of leadership and the cultural change toward patient-centered care in forming these organizations,” she said.

Alicia Ault and Naseem Miller contributed to this report.

To view a video interview with Mr. Blum, scan this QR code.

Physicians may need to invest in health information technology, said Jonathan Blum, director of the Center for Medicare Management.

Source Elsevier Global Medical News

The medical model of “the more you do, the more you make” is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.

Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).

HealthCare Partners' physicians in California have been working in the global capitation market for many years and Dr. Chin said this experience will help them transition to being an ACO.

“We have had the experience of improving outcomes and reducing costs, improving patient satisfaction, improving the patient experience in our model,” Dr. Chin said. “Some of the common goals of the ACO are things that we are doing today.”

This year is likely to be a “learning year” for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records. Without that investment in technology, it's nearly impossible to become efficient and improve quality because paper charts are intractable to analysis, according to Dr. Chin.

But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.

ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.

Officials at the Centers for Medicare and Medicaid Services released a proposed regulation on Mar. 31 outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers.

An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.

Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings.

The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.

The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.

More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-sided risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-sided risk model.

Physicians' groups see pluses and minuses in the government's vision for ACOs.

The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn't provide much incentive for small- and medium-size practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.

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.

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.”

The NCQA recently concluded testing of its standards with 10 organizations that represent IPAs, multispecialty practice groups, and integrated delivery systems. One issue that came up during the testing is the importance of leadership within the ACO.

“We can define structural features that are important for [ACOs], but I think you cannot underestimate the importance of leadership and the cultural change toward patient-centered care in forming these organizations,” she said.

Alicia Ault and Naseem Miller contributed to this report.

To view a video interview with Mr. Blum, scan this QR code.

Physicians may need to invest in health information technology, said Jonathan Blum, director of the Center for Medicare Management.

Source Elsevier Global Medical News

The medical model of “the more you do, the more you make” is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.

Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).

HealthCare Partners' physicians in California have been working in the global capitation market for many years and Dr. Chin said this experience will help them transition to being an ACO.

“We have had the experience of improving outcomes and reducing costs, improving patient satisfaction, improving the patient experience in our model,” Dr. Chin said. “Some of the common goals of the ACO are things that we are doing today.”

This year is likely to be a “learning year” for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records. Without that investment in technology, it's nearly impossible to become efficient and improve quality because paper charts are intractable to analysis, according to Dr. Chin.

But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.

ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.

Officials at the Centers for Medicare and Medicaid Services released a proposed regulation on Mar. 31 outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers.

An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.

Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings.

The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.

The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.

More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-sided risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-sided risk model.

Physicians' groups see pluses and minuses in the government's vision for ACOs.

The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn't provide much incentive for small- and medium-size practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.

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.

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.”

The NCQA recently concluded testing of its standards with 10 organizations that represent IPAs, multispecialty practice groups, and integrated delivery systems. One issue that came up during the testing is the importance of leadership within the ACO.

“We can define structural features that are important for [ACOs], but I think you cannot underestimate the importance of leadership and the cultural change toward patient-centered care in forming these organizations,” she said.

Alicia Ault and Naseem Miller contributed to this report.

To view a video interview with Mr. Blum, scan this QR code.

Physicians may need to invest in health information technology, said Jonathan Blum, director of the Center for Medicare Management.

Source Elsevier Global Medical News

Elderly Women Miss Screening

Many women aged 65 and older have never been tested for osteoporosis risk, according to a report from the Centers for Disease Control and Prevention. The agency examined the women's history of bone mass and bone density screening as recommended by the U.S. Preventive Services Task Force for Medicare beneficiaries. Varying by race, large percentages of women 65 and older reported never having received either of the tests. Among black women, 62% said they had never been tested. The figures for Medicare-eligible American Indian/Alaska Native women and white women who were never tested were 54% and 33%, respectively. The report found similar shortcomings in the percentages of elderly people getting other recommended – and often free – preventive services, such as vaccinations or diabetes and cancer screening.

Drug Injuries Are Up

The number of people treated in hospitals after they took the wrong medicine or an incorrect dose jumped by more than half, from 2004 to 2008, the Agency for Healthcare Research and Quality reported. Pain killers, antibiotics, tranquilizers/antidepressants, and corticosteroids/other hormones headed the list of medications for which people were treated in emergency departments and released, the agency said. Corticosteroids, painkillers, blood thinners, drugs to treat cancer and immune system disorders, and heart and blood pressure medicines led to the most people being admitted to hospitals. More than half of people hospitalized were aged 65 years or older; children and teenagers accounted for 22% of the emergency department cases. More women than men suffered injuries and side effects, according to the report.

NIH Begins Function Study

Researchers at the National Institutes of Health have begun recruiting 9,000 Medicare beneficiaries for a study of how daily function changes with age. The National Health and Aging Trends Study will look specifically at how aging affects walking, dressing, other activities of daily living. Study participants will be interviewed in person in 2011 and then once a year. Researchers also will conduct short tests of physical performance. “The recently observed trend toward decreasing rates of disability identified by the National Long Term Care Survey and other national surveys may have leveled off, and this has serious implications,” Richard Suzman, Ph.D., director of the division of behavioral and social research at the National Institute on Aging, said in a statement. The National Long Term Care Survey found that physical disability dropped significantly among older people between 1982 and 2005.

Congress Members Want Help

In a letter, members of the House Energy and Commerce Committee asked 51 physician groups, including the American College of Rheumatology, to help craft a “permanent” and “sustainable” solution to the Medicare physician-payment system. Under the current system, based on the sustainable growth rate (SGR) formula, physicians will face a 29% cut to Medicare payments in 2012. The letter criticized the current formula and asked the physicians to suggest alternatives. The lawmakers said they are seeking payment models that reduce spending, pay providers fairly, and pay for services according to their value to beneficiaries.

Bill Would Expose Billing

Sen. Ron Wyden (D-Ore.) and Sen. Charles Grassley (R-Iowa) have introduced a bill that would require the government to disclose what physicians earn from Medicare. The Medicare Data Access for Transparency and Accountability Act would keep patient information blinded. “Taxpayers should have a right to see how their hard-earned dollars are being spent,” said Sen. Grassley in a statement on the Senate floor. “Also, if doctors know their billing information is public, it might deter some wasteful practices and overbilling.” Medicare has been prohibited from making the data public since a 1979 court ruling. Physician organizations, most notably the American Medical Association, have also opposed the release of the data, citing doctors' right to privacy.

Medical Boards Fail on Discipline

State medical boards failed to discipline more than half of doctors who either lost their clinical privileges or had them restricted by the hospitals where they worked, according to a report from advocacy group Public Citizen. In all, 10,672 physicians were listed in the National Practitioner Data Bank as having restricted or revoked clinical privileges, yet 5,887 (55%) of them did not see any licensing action from their states, the group reported. Of those escaping licensing actions, 1,119 had been otherwise disciplined for incompetence, negligence, or malpractice, and 605 were disciplined for substandard care, the report said. Hospital boards had identified 220 of the otherwise-unsanctioned doctors as “an immediate threat to health or safety,” according to Public Citizen.

Elderly Women Miss Screening

Many women aged 65 and older have never been tested for osteoporosis risk, according to a report from the Centers for Disease Control and Prevention. The agency examined the women's history of bone mass and bone density screening as recommended by the U.S. Preventive Services Task Force for Medicare beneficiaries. Varying by race, large percentages of women 65 and older reported never having received either of the tests. Among black women, 62% said they had never been tested. The figures for Medicare-eligible American Indian/Alaska Native women and white women who were never tested were 54% and 33%, respectively. The report found similar shortcomings in the percentages of elderly people getting other recommended – and often free – preventive services, such as vaccinations or diabetes and cancer screening.

Drug Injuries Are Up

The number of people treated in hospitals after they took the wrong medicine or an incorrect dose jumped by more than half, from 2004 to 2008, the Agency for Healthcare Research and Quality reported. Pain killers, antibiotics, tranquilizers/antidepressants, and corticosteroids/other hormones headed the list of medications for which people were treated in emergency departments and released, the agency said. Corticosteroids, painkillers, blood thinners, drugs to treat cancer and immune system disorders, and heart and blood pressure medicines led to the most people being admitted to hospitals. More than half of people hospitalized were aged 65 years or older; children and teenagers accounted for 22% of the emergency department cases. More women than men suffered injuries and side effects, according to the report.

NIH Begins Function Study

Researchers at the National Institutes of Health have begun recruiting 9,000 Medicare beneficiaries for a study of how daily function changes with age. The National Health and Aging Trends Study will look specifically at how aging affects walking, dressing, other activities of daily living. Study participants will be interviewed in person in 2011 and then once a year. Researchers also will conduct short tests of physical performance. “The recently observed trend toward decreasing rates of disability identified by the National Long Term Care Survey and other national surveys may have leveled off, and this has serious implications,” Richard Suzman, Ph.D., director of the division of behavioral and social research at the National Institute on Aging, said in a statement. The National Long Term Care Survey found that physical disability dropped significantly among older people between 1982 and 2005.

Congress Members Want Help

In a letter, members of the House Energy and Commerce Committee asked 51 physician groups, including the American College of Rheumatology, to help craft a “permanent” and “sustainable” solution to the Medicare physician-payment system. Under the current system, based on the sustainable growth rate (SGR) formula, physicians will face a 29% cut to Medicare payments in 2012. The letter criticized the current formula and asked the physicians to suggest alternatives. The lawmakers said they are seeking payment models that reduce spending, pay providers fairly, and pay for services according to their value to beneficiaries.

Bill Would Expose Billing

Sen. Ron Wyden (D-Ore.) and Sen. Charles Grassley (R-Iowa) have introduced a bill that would require the government to disclose what physicians earn from Medicare. The Medicare Data Access for Transparency and Accountability Act would keep patient information blinded. “Taxpayers should have a right to see how their hard-earned dollars are being spent,” said Sen. Grassley in a statement on the Senate floor. “Also, if doctors know their billing information is public, it might deter some wasteful practices and overbilling.” Medicare has been prohibited from making the data public since a 1979 court ruling. Physician organizations, most notably the American Medical Association, have also opposed the release of the data, citing doctors' right to privacy.

Medical Boards Fail on Discipline

State medical boards failed to discipline more than half of doctors who either lost their clinical privileges or had them restricted by the hospitals where they worked, according to a report from advocacy group Public Citizen. In all, 10,672 physicians were listed in the National Practitioner Data Bank as having restricted or revoked clinical privileges, yet 5,887 (55%) of them did not see any licensing action from their states, the group reported. Of those escaping licensing actions, 1,119 had been otherwise disciplined for incompetence, negligence, or malpractice, and 605 were disciplined for substandard care, the report said. Hospital boards had identified 220 of the otherwise-unsanctioned doctors as “an immediate threat to health or safety,” according to Public Citizen.

Elderly Women Miss Screening

Many women aged 65 and older have never been tested for osteoporosis risk, according to a report from the Centers for Disease Control and Prevention. The agency examined the women's history of bone mass and bone density screening as recommended by the U.S. Preventive Services Task Force for Medicare beneficiaries. Varying by race, large percentages of women 65 and older reported never having received either of the tests. Among black women, 62% said they had never been tested. The figures for Medicare-eligible American Indian/Alaska Native women and white women who were never tested were 54% and 33%, respectively. The report found similar shortcomings in the percentages of elderly people getting other recommended – and often free – preventive services, such as vaccinations or diabetes and cancer screening.

Drug Injuries Are Up

The number of people treated in hospitals after they took the wrong medicine or an incorrect dose jumped by more than half, from 2004 to 2008, the Agency for Healthcare Research and Quality reported. Pain killers, antibiotics, tranquilizers/antidepressants, and corticosteroids/other hormones headed the list of medications for which people were treated in emergency departments and released, the agency said. Corticosteroids, painkillers, blood thinners, drugs to treat cancer and immune system disorders, and heart and blood pressure medicines led to the most people being admitted to hospitals. More than half of people hospitalized were aged 65 years or older; children and teenagers accounted for 22% of the emergency department cases. More women than men suffered injuries and side effects, according to the report.

NIH Begins Function Study

Researchers at the National Institutes of Health have begun recruiting 9,000 Medicare beneficiaries for a study of how daily function changes with age. The National Health and Aging Trends Study will look specifically at how aging affects walking, dressing, other activities of daily living. Study participants will be interviewed in person in 2011 and then once a year. Researchers also will conduct short tests of physical performance. “The recently observed trend toward decreasing rates of disability identified by the National Long Term Care Survey and other national surveys may have leveled off, and this has serious implications,” Richard Suzman, Ph.D., director of the division of behavioral and social research at the National Institute on Aging, said in a statement. The National Long Term Care Survey found that physical disability dropped significantly among older people between 1982 and 2005.

Congress Members Want Help

In a letter, members of the House Energy and Commerce Committee asked 51 physician groups, including the American College of Rheumatology, to help craft a “permanent” and “sustainable” solution to the Medicare physician-payment system. Under the current system, based on the sustainable growth rate (SGR) formula, physicians will face a 29% cut to Medicare payments in 2012. The letter criticized the current formula and asked the physicians to suggest alternatives. The lawmakers said they are seeking payment models that reduce spending, pay providers fairly, and pay for services according to their value to beneficiaries.

Bill Would Expose Billing

Sen. Ron Wyden (D-Ore.) and Sen. Charles Grassley (R-Iowa) have introduced a bill that would require the government to disclose what physicians earn from Medicare. The Medicare Data Access for Transparency and Accountability Act would keep patient information blinded. “Taxpayers should have a right to see how their hard-earned dollars are being spent,” said Sen. Grassley in a statement on the Senate floor. “Also, if doctors know their billing information is public, it might deter some wasteful practices and overbilling.” Medicare has been prohibited from making the data public since a 1979 court ruling. Physician organizations, most notably the American Medical Association, have also opposed the release of the data, citing doctors' right to privacy.

Medical Boards Fail on Discipline

State medical boards failed to discipline more than half of doctors who either lost their clinical privileges or had them restricted by the hospitals where they worked, according to a report from advocacy group Public Citizen. In all, 10,672 physicians were listed in the National Practitioner Data Bank as having restricted or revoked clinical privileges, yet 5,887 (55%) of them did not see any licensing action from their states, the group reported. Of those escaping licensing actions, 1,119 had been otherwise disciplined for incompetence, negligence, or malpractice, and 605 were disciplined for substandard care, the report said. Hospital boards had identified 220 of the otherwise-unsanctioned doctors as “an immediate threat to health or safety,” according to Public Citizen.

NEW YORK – Evidence is emerging that treating hyperuricemia and gout could help control comorbid cardiovascular disease, according to Dr. Michael H. Pillinger, director of the rheumatology fellowship program at New York University and director of rheumatology at the Manhattan VA Hospital, New York.

Patients with gout tend to have an average of three to four comorbidities, including hypertension, hyperlipidemia, kidney disease, diabetes, and coronary artery disease.

Now there is some limited evidence indicating that lowering uric acid may help to reduce cardiovascular mortality, Dr. Pillinger said at the meeting.

Data presented at last year's American College of Rheumatology's annual meeting show that cardiovascular mortality dropped by nearly half among patients taking urate-lowering therapy.

The study, which looked at a database of about 45,000 Taiwanese hyperuricemia patients, also showed that stroke mortality decreased significantly when urate levels were lowered.

And the researchers observed a larger decrease in mortality when patients on the drug actually achieved urate lowering than when they did not.

“This would suggest that there really is a relationship between uric acid and cardiovascular disease,” Dr. Pillinger said.

More research will be needed to know for sure whether lowering uric acid could benefit cardiovascular disease, he said.

And other questions remain as well: For example, is it hyperuricemia or gout that conveys the risk for coronary artery disease?

That's unclear, because most of the current studies have been done comparing only hyperuricemia to cardiac outcomes, he said.

Another Taiwanese database study, published last year, compared patients with hyperuricemia and those with gout vs. control patients.

After adjusting for comorbidities, the researchers concluded that only gout was a risk for cardiovascular mortality (Rheumatology [Oxford] 2010;49:141–6). But Dr. Pillinger said he's not convinced that the data should have been adjusted, because if gout or hyperuricemia themselves contribute to the comorbidities, then such an adjustment may lead to an underestimation of the impact of uric acid.

To shed more light on the role of gout and hyperuricemia in cardiovascular disease, researchers at NYU have been recruiting patients to a study assessing coronary artery disease in men with hyperuricemia, in those with gout, and in control patients.

Preliminary data from the prospective cohort study indicate that coronary artery disease increases in a stepwise fashion from hyperuricemia to gout, according to Dr. Pillinger.

The researchers are also starting to look at how hyperuricemic patients with lower levels of uric acid (6.9–9.0 mg/dL), compared with those who have higher levels (greater than 9.0 mg/dL).

In that preliminary subanalysis, patients with the highest levels of uric acid had the highest risk for coronary artery disease and MI.

“I think this is beginning to suggest that there's at least an intermediate risk from having elevated uric acid,” Dr. Pillinger said.

Some studies have also shown that treatment of the inflammation associated with gout could help in cardiovascular disease.

Researchers performed an analysis of nearly 1,300 patients in the New York VA gout cohort.

About half of the patients were on chronic colchicine therapy and half were not taking colchicine.

The cross-sectional study, which was presented at the 2010 ACR annual meeting, found that patients who took colchicine had more than a 50% decrease in MI rates, compared with those who were not on the drug.

Patients also had a lower risk of death and a lower C-reactive protein level, but these results did not achieve statistical significance. “This is very provocative,” Dr. Pillinger said.

A recent study based on data from National Health and Nutrition Examination Survey shows that an estimated 32 million Americans, one-fifth of the U.S. population, have hyperuricemia, which precedes gout.

Gout rates also are increasing in the U.S. NHANES data show a 1.2% increase in gout among U.S. adults, from 2.7% during 1988–1994 to 3.9% during 2007–2008. Men and older adults were the most likely to be at increased risk for gout (

Dr. Pillinger said that he had no relevant financial conflicts of interest to report.

Patients with the highest levels of uric acid had the highest risk for coronary artery disease and MI.

Source DR. PILLINGER

NEW YORK – Evidence is emerging that treating hyperuricemia and gout could help control comorbid cardiovascular disease, according to Dr. Michael H. Pillinger, director of the rheumatology fellowship program at New York University and director of rheumatology at the Manhattan VA Hospital, New York.

Patients with gout tend to have an average of three to four comorbidities, including hypertension, hyperlipidemia, kidney disease, diabetes, and coronary artery disease.

Now there is some limited evidence indicating that lowering uric acid may help to reduce cardiovascular mortality, Dr. Pillinger said at the meeting.

Data presented at last year's American College of Rheumatology's annual meeting show that cardiovascular mortality dropped by nearly half among patients taking urate-lowering therapy.

The study, which looked at a database of about 45,000 Taiwanese hyperuricemia patients, also showed that stroke mortality decreased significantly when urate levels were lowered.

And the researchers observed a larger decrease in mortality when patients on the drug actually achieved urate lowering than when they did not.

“This would suggest that there really is a relationship between uric acid and cardiovascular disease,” Dr. Pillinger said.

More research will be needed to know for sure whether lowering uric acid could benefit cardiovascular disease, he said.

And other questions remain as well: For example, is it hyperuricemia or gout that conveys the risk for coronary artery disease?

That's unclear, because most of the current studies have been done comparing only hyperuricemia to cardiac outcomes, he said.

Another Taiwanese database study, published last year, compared patients with hyperuricemia and those with gout vs. control patients.

After adjusting for comorbidities, the researchers concluded that only gout was a risk for cardiovascular mortality (Rheumatology [Oxford] 2010;49:141–6). But Dr. Pillinger said he's not convinced that the data should have been adjusted, because if gout or hyperuricemia themselves contribute to the comorbidities, then such an adjustment may lead to an underestimation of the impact of uric acid.

To shed more light on the role of gout and hyperuricemia in cardiovascular disease, researchers at NYU have been recruiting patients to a study assessing coronary artery disease in men with hyperuricemia, in those with gout, and in control patients.

Preliminary data from the prospective cohort study indicate that coronary artery disease increases in a stepwise fashion from hyperuricemia to gout, according to Dr. Pillinger.

The researchers are also starting to look at how hyperuricemic patients with lower levels of uric acid (6.9–9.0 mg/dL), compared with those who have higher levels (greater than 9.0 mg/dL).

In that preliminary subanalysis, patients with the highest levels of uric acid had the highest risk for coronary artery disease and MI.

“I think this is beginning to suggest that there's at least an intermediate risk from having elevated uric acid,” Dr. Pillinger said.

Some studies have also shown that treatment of the inflammation associated with gout could help in cardiovascular disease.

Researchers performed an analysis of nearly 1,300 patients in the New York VA gout cohort.

About half of the patients were on chronic colchicine therapy and half were not taking colchicine.

The cross-sectional study, which was presented at the 2010 ACR annual meeting, found that patients who took colchicine had more than a 50% decrease in MI rates, compared with those who were not on the drug.

Patients also had a lower risk of death and a lower C-reactive protein level, but these results did not achieve statistical significance. “This is very provocative,” Dr. Pillinger said.

A recent study based on data from National Health and Nutrition Examination Survey shows that an estimated 32 million Americans, one-fifth of the U.S. population, have hyperuricemia, which precedes gout.

Gout rates also are increasing in the U.S. NHANES data show a 1.2% increase in gout among U.S. adults, from 2.7% during 1988–1994 to 3.9% during 2007–2008. Men and older adults were the most likely to be at increased risk for gout (

Dr. Pillinger said that he had no relevant financial conflicts of interest to report.

Patients with the highest levels of uric acid had the highest risk for coronary artery disease and MI.

Source DR. PILLINGER

NEW YORK – Evidence is emerging that treating hyperuricemia and gout could help control comorbid cardiovascular disease, according to Dr. Michael H. Pillinger, director of the rheumatology fellowship program at New York University and director of rheumatology at the Manhattan VA Hospital, New York.

Patients with gout tend to have an average of three to four comorbidities, including hypertension, hyperlipidemia, kidney disease, diabetes, and coronary artery disease.

Now there is some limited evidence indicating that lowering uric acid may help to reduce cardiovascular mortality, Dr. Pillinger said at the meeting.

Data presented at last year's American College of Rheumatology's annual meeting show that cardiovascular mortality dropped by nearly half among patients taking urate-lowering therapy.

The study, which looked at a database of about 45,000 Taiwanese hyperuricemia patients, also showed that stroke mortality decreased significantly when urate levels were lowered.

And the researchers observed a larger decrease in mortality when patients on the drug actually achieved urate lowering than when they did not.

“This would suggest that there really is a relationship between uric acid and cardiovascular disease,” Dr. Pillinger said.

More research will be needed to know for sure whether lowering uric acid could benefit cardiovascular disease, he said.

And other questions remain as well: For example, is it hyperuricemia or gout that conveys the risk for coronary artery disease?

That's unclear, because most of the current studies have been done comparing only hyperuricemia to cardiac outcomes, he said.

Another Taiwanese database study, published last year, compared patients with hyperuricemia and those with gout vs. control patients.

After adjusting for comorbidities, the researchers concluded that only gout was a risk for cardiovascular mortality (Rheumatology [Oxford] 2010;49:141–6). But Dr. Pillinger said he's not convinced that the data should have been adjusted, because if gout or hyperuricemia themselves contribute to the comorbidities, then such an adjustment may lead to an underestimation of the impact of uric acid.

To shed more light on the role of gout and hyperuricemia in cardiovascular disease, researchers at NYU have been recruiting patients to a study assessing coronary artery disease in men with hyperuricemia, in those with gout, and in control patients.

Preliminary data from the prospective cohort study indicate that coronary artery disease increases in a stepwise fashion from hyperuricemia to gout, according to Dr. Pillinger.

The researchers are also starting to look at how hyperuricemic patients with lower levels of uric acid (6.9–9.0 mg/dL), compared with those who have higher levels (greater than 9.0 mg/dL).

In that preliminary subanalysis, patients with the highest levels of uric acid had the highest risk for coronary artery disease and MI.

“I think this is beginning to suggest that there's at least an intermediate risk from having elevated uric acid,” Dr. Pillinger said.

Some studies have also shown that treatment of the inflammation associated with gout could help in cardiovascular disease.

Researchers performed an analysis of nearly 1,300 patients in the New York VA gout cohort.

About half of the patients were on chronic colchicine therapy and half were not taking colchicine.

The cross-sectional study, which was presented at the 2010 ACR annual meeting, found that patients who took colchicine had more than a 50% decrease in MI rates, compared with those who were not on the drug.

Patients also had a lower risk of death and a lower C-reactive protein level, but these results did not achieve statistical significance. “This is very provocative,” Dr. Pillinger said.

A recent study based on data from National Health and Nutrition Examination Survey shows that an estimated 32 million Americans, one-fifth of the U.S. population, have hyperuricemia, which precedes gout.

Gout rates also are increasing in the U.S. NHANES data show a 1.2% increase in gout among U.S. adults, from 2.7% during 1988–1994 to 3.9% during 2007–2008. Men and older adults were the most likely to be at increased risk for gout (

Dr. Pillinger said that he had no relevant financial conflicts of interest to report.

Patients with the highest levels of uric acid had the highest risk for coronary artery disease and MI.

Source DR. PILLINGER

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, said Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, she said.

Dr. Lane, who was an investigator for Pfizer's anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may “bear fruit in the long term.”

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, said Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, she said.

Dr. Lane, who was an investigator for Pfizer's anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may “bear fruit in the long term.”

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, said Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, she said.

Dr. Lane, who was an investigator for Pfizer's anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may “bear fruit in the long term.”

Physicians can now send data to the federal government to qualify for thousands of dollars in bonus payments under the new Medicare electronic health record incentive program.

The program officially began on Jan. 3, but April 18 was the first day that physicians and other eligible providers could submit data on their “meaningful use” of electronic health records (EHRs). In order to qualify for Medicare incentive payments for 2011, physicians must report on at least 90 days of meaningful use occurring during this calendar year. Oct. 1, 2011, is the last day that physicians can begin their 90-day reporting period to receive a 2011 incentive payment.

The first checks for the Medicare incentive program are expected to go out in May, according to the Centers for Medicare and Medicaid Services.

The incentive program, which was authorized under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, offers payments to physicians who use health information technology to improve patient care. Federal regulations governing the program spell out how physicians and hospitals can meet standards for the meaningful use of certified EHR technology.

Physicians that meet the criteria are eligible to receive up to $44,000 over 5 years under the Medicare program. Physicians can still receive bonuses if they begin their meaningful use of the technology later, but they must qualify for the program before the end of 2012 to get all the available incentives.

A similar program is in place under the Medicaid program, with physicians eligible to receive up to $64,000 over 6 years for the adoption and use of certified EHR technology.

As part of the attestation process, physicians and other eligible providers must go online to report data on a number of meaningful use and quality measures established by CMS. Through the online portal, physicians can report the numerator, denominator, and any potential exclusions for the objectives.

They can also attest that they have successfully met the program requirements. For example, the meaningful use regulations require that providers maintain an up-to-date accounting of current and active diagnoses. To be eligible for incentives, providers must report that more than 80% of all unique patients seen by the provider have at least one entry, or an indicator that no problems are known for the patients. The data must be recorded in a structured format.

“There is a great deal of interest in the meaningful use program,” said William Underwood, a senior associate in the division of medical practice, professionalism, and quality at the American College of Physicians.

But while interest is high, that doesn't mean physicians will be clamoring to report on meaningful use immediately. Right now, physicians in both small and large practices are struggling with logistical hurdles, Mr. Underwood said.

For example, there is currently not a process in place to allow practice administrators to submit meaningful use data to CMS on behalf of large physician practices. The current setup requires a physician to report the information.

While CMS officials plan to address this, it hasn't happened yet, Mr. Underwood said.

Some small practices are having difficulty meeting meaningful use thresholds because other entities are not exchanging information with them regarding labs and referrals. And practices of all sizes are waiting for vendors to finish rolling out updates that show they are in compliance with meaningful use certification, he said.

Dr. Steven Waldren, director of the Center for Health IT at the American Academy of Family Physicians, agreed that while some physicians will submit data immediately, a large portion are still trying to figure out what they need to do to meet meaningful use requirements and ensure that their EHR system is certified. It may take until at least October to get a real sense of how many physicians plan to participate, he said.

Oct. 1, 2011, is the last day that physicians can begin their 90-day reporting period to receive a 2011 incentive payment.

Source ©Yanik Chauvin/iStockphoto.com

Physicians can now send data to the federal government to qualify for thousands of dollars in bonus payments under the new Medicare electronic health record incentive program.

The program officially began on Jan. 3, but April 18 was the first day that physicians and other eligible providers could submit data on their “meaningful use” of electronic health records (EHRs). In order to qualify for Medicare incentive payments for 2011, physicians must report on at least 90 days of meaningful use occurring during this calendar year. Oct. 1, 2011, is the last day that physicians can begin their 90-day reporting period to receive a 2011 incentive payment.

The first checks for the Medicare incentive program are expected to go out in May, according to the Centers for Medicare and Medicaid Services.

The incentive program, which was authorized under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, offers payments to physicians who use health information technology to improve patient care. Federal regulations governing the program spell out how physicians and hospitals can meet standards for the meaningful use of certified EHR technology.

Physicians that meet the criteria are eligible to receive up to $44,000 over 5 years under the Medicare program. Physicians can still receive bonuses if they begin their meaningful use of the technology later, but they must qualify for the program before the end of 2012 to get all the available incentives.

A similar program is in place under the Medicaid program, with physicians eligible to receive up to $64,000 over 6 years for the adoption and use of certified EHR technology.

As part of the attestation process, physicians and other eligible providers must go online to report data on a number of meaningful use and quality measures established by CMS. Through the online portal, physicians can report the numerator, denominator, and any potential exclusions for the objectives.

They can also attest that they have successfully met the program requirements. For example, the meaningful use regulations require that providers maintain an up-to-date accounting of current and active diagnoses. To be eligible for incentives, providers must report that more than 80% of all unique patients seen by the provider have at least one entry, or an indicator that no problems are known for the patients. The data must be recorded in a structured format.

“There is a great deal of interest in the meaningful use program,” said William Underwood, a senior associate in the division of medical practice, professionalism, and quality at the American College of Physicians.

But while interest is high, that doesn't mean physicians will be clamoring to report on meaningful use immediately. Right now, physicians in both small and large practices are struggling with logistical hurdles, Mr. Underwood said.

For example, there is currently not a process in place to allow practice administrators to submit meaningful use data to CMS on behalf of large physician practices. The current setup requires a physician to report the information.

While CMS officials plan to address this, it hasn't happened yet, Mr. Underwood said.

Some small practices are having difficulty meeting meaningful use thresholds because other entities are not exchanging information with them regarding labs and referrals. And practices of all sizes are waiting for vendors to finish rolling out updates that show they are in compliance with meaningful use certification, he said.

Dr. Steven Waldren, director of the Center for Health IT at the American Academy of Family Physicians, agreed that while some physicians will submit data immediately, a large portion are still trying to figure out what they need to do to meet meaningful use requirements and ensure that their EHR system is certified. It may take until at least October to get a real sense of how many physicians plan to participate, he said.

Oct. 1, 2011, is the last day that physicians can begin their 90-day reporting period to receive a 2011 incentive payment.

Source ©Yanik Chauvin/iStockphoto.com

Physicians can now send data to the federal government to qualify for thousands of dollars in bonus payments under the new Medicare electronic health record incentive program.

The program officially began on Jan. 3, but April 18 was the first day that physicians and other eligible providers could submit data on their “meaningful use” of electronic health records (EHRs). In order to qualify for Medicare incentive payments for 2011, physicians must report on at least 90 days of meaningful use occurring during this calendar year. Oct. 1, 2011, is the last day that physicians can begin their 90-day reporting period to receive a 2011 incentive payment.

The first checks for the Medicare incentive program are expected to go out in May, according to the Centers for Medicare and Medicaid Services.

The incentive program, which was authorized under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, offers payments to physicians who use health information technology to improve patient care. Federal regulations governing the program spell out how physicians and hospitals can meet standards for the meaningful use of certified EHR technology.

Physicians that meet the criteria are eligible to receive up to $44,000 over 5 years under the Medicare program. Physicians can still receive bonuses if they begin their meaningful use of the technology later, but they must qualify for the program before the end of 2012 to get all the available incentives.

A similar program is in place under the Medicaid program, with physicians eligible to receive up to $64,000 over 6 years for the adoption and use of certified EHR technology.

As part of the attestation process, physicians and other eligible providers must go online to report data on a number of meaningful use and quality measures established by CMS. Through the online portal, physicians can report the numerator, denominator, and any potential exclusions for the objectives.

They can also attest that they have successfully met the program requirements. For example, the meaningful use regulations require that providers maintain an up-to-date accounting of current and active diagnoses. To be eligible for incentives, providers must report that more than 80% of all unique patients seen by the provider have at least one entry, or an indicator that no problems are known for the patients. The data must be recorded in a structured format.

“There is a great deal of interest in the meaningful use program,” said William Underwood, a senior associate in the division of medical practice, professionalism, and quality at the American College of Physicians.

But while interest is high, that doesn't mean physicians will be clamoring to report on meaningful use immediately. Right now, physicians in both small and large practices are struggling with logistical hurdles, Mr. Underwood said.

For example, there is currently not a process in place to allow practice administrators to submit meaningful use data to CMS on behalf of large physician practices. The current setup requires a physician to report the information.

While CMS officials plan to address this, it hasn't happened yet, Mr. Underwood said.

Some small practices are having difficulty meeting meaningful use thresholds because other entities are not exchanging information with them regarding labs and referrals. And practices of all sizes are waiting for vendors to finish rolling out updates that show they are in compliance with meaningful use certification, he said.

Dr. Steven Waldren, director of the Center for Health IT at the American Academy of Family Physicians, agreed that while some physicians will submit data immediately, a large portion are still trying to figure out what they need to do to meet meaningful use requirements and ensure that their EHR system is certified. It may take until at least October to get a real sense of how many physicians plan to participate, he said.

Oct. 1, 2011, is the last day that physicians can begin their 90-day reporting period to receive a 2011 incentive payment.

Source ©Yanik Chauvin/iStockphoto.com

After months of deliberation, officials at the Centers for Medicare and Medicaid Services released a proposed rule outlining how physicians, hospitals, and long-term care facilities can work together to form accountable care organizations and share in the savings they achieve for Medicare.

The voluntary program was created under the Affordable Care Act and will begin in January 2012.

Under the proposal, accountable care organizations (ACOs) could include physicians in group practice, networks of individual practices, hospitals that employ physicians, and partnerships among these entities, as well as other providers. The idea is for ACOs to be a partnership among a range of physicians, including specialists and primary care providers. However, only primary care providers will be able to form an ACO, according to CMS.

According to the proposed rule, providers in the ACO would continue to receive their regular fee-for-service payments under Medicare, but they could also qualify for additional payment if their care resulted in savings to the program.

The proposed framework requires that ACOs meet certain quality standards and demonstrate that they have reduced costs in order to be eligible to share in any savings. The proposal outlines 65 quality measures in five quality domains: patient experience, care coordination, patient safety, preventive health, and care of at-risk and frail elderly populations.

“ACOs aren't just a new way to pay for care; they're a new model for the organization and delivery of the care under Medicare,” said Dr. Donald Berwick, CMS administrator, during a press conference to announce the proposed rule.

Dr. Berwick said he doesn't know how many ACOs will form under the program, but that the level of interest is “enormous.”

Since the Affordable Care Act was passed last year, the health care community has been buzzing about how ACOs might be structured and if they could succeed in reducing health care costs.

Integrated care organizations like Geisinger Health System in Danville, Pa., are considered to have a leg up because their hospital and outpatient care is already coordinated.

But Dr. Berwick said that the proposal allows for ACOs at various levels of development to participate. For example, less-developed ACOs can choose to receive shared savings for 2 years before assuming risk. Organizations that are more matureocan assume risk immediately but be eligible for greater levels of shared savings.

“Our aim is to create on-ramps that will allow many to participate, depending on the different levels of maturity they are starting with,” said Dr. Berwick.

CMS officials estimate that the program could result in as much as $960 million in Medicare savings over a period of 3 years.

Although federal officials said that they expect the coordinated care to pay dividends in savings to Medicare, ACOs will not be set up like HMOs. Medicare beneficiaries will continue to be able to see their choice of providers under fee-for-service Medicare. Providers will be the ones that enroll in ACOs and must notify patients that they are receiving care within an ACO.

In addition to the ACO proposed rule, the Department of Justice and the Federal Trade Commission have issued guidance on how physicians and hospitals that form an ACO can steer clear of antitrust laws.

Officials at the CMS and the Office of the Inspector General have also issued a notice on potential waivers that could be granted to ACOs in connection with the shared savings program, and the Internal Revenue Service has issued new guidance for tax-exempt hospitals that are seeking to participate in the program.

The CMS will be accepting comments on the proposed rule for 60 days. The agency also plans a series of open-door forums and listening sessions to explain the proposal and to get feedback from the public.

At press time, the American Medical Association said that it was reviewing the proposed rule and the policy statements from the Federal Trade Commission and the Department of Justice. In a statement, Dr. Jeremy A. Lazarus, the speaker of the AMA House of Delegates, said that ACOs offer “great promise” but that there are still a number of barriers to success, including the large capital requirements to fund an ACO and to make the necessary changes to individual physician practices.

After months of deliberation, officials at the Centers for Medicare and Medicaid Services released a proposed rule outlining how physicians, hospitals, and long-term care facilities can work together to form accountable care organizations and share in the savings they achieve for Medicare.

The voluntary program was created under the Affordable Care Act and will begin in January 2012.

Under the proposal, accountable care organizations (ACOs) could include physicians in group practice, networks of individual practices, hospitals that employ physicians, and partnerships among these entities, as well as other providers. The idea is for ACOs to be a partnership among a range of physicians, including specialists and primary care providers. However, only primary care providers will be able to form an ACO, according to CMS.

According to the proposed rule, providers in the ACO would continue to receive their regular fee-for-service payments under Medicare, but they could also qualify for additional payment if their care resulted in savings to the program.

The proposed framework requires that ACOs meet certain quality standards and demonstrate that they have reduced costs in order to be eligible to share in any savings. The proposal outlines 65 quality measures in five quality domains: patient experience, care coordination, patient safety, preventive health, and care of at-risk and frail elderly populations.

“ACOs aren't just a new way to pay for care; they're a new model for the organization and delivery of the care under Medicare,” said Dr. Donald Berwick, CMS administrator, during a press conference to announce the proposed rule.

Dr. Berwick said he doesn't know how many ACOs will form under the program, but that the level of interest is “enormous.”

Since the Affordable Care Act was passed last year, the health care community has been buzzing about how ACOs might be structured and if they could succeed in reducing health care costs.

Integrated care organizations like Geisinger Health System in Danville, Pa., are considered to have a leg up because their hospital and outpatient care is already coordinated.

But Dr. Berwick said that the proposal allows for ACOs at various levels of development to participate. For example, less-developed ACOs can choose to receive shared savings for 2 years before assuming risk. Organizations that are more matureocan assume risk immediately but be eligible for greater levels of shared savings.

“Our aim is to create on-ramps that will allow many to participate, depending on the different levels of maturity they are starting with,” said Dr. Berwick.

CMS officials estimate that the program could result in as much as $960 million in Medicare savings over a period of 3 years.

Although federal officials said that they expect the coordinated care to pay dividends in savings to Medicare, ACOs will not be set up like HMOs. Medicare beneficiaries will continue to be able to see their choice of providers under fee-for-service Medicare. Providers will be the ones that enroll in ACOs and must notify patients that they are receiving care within an ACO.

In addition to the ACO proposed rule, the Department of Justice and the Federal Trade Commission have issued guidance on how physicians and hospitals that form an ACO can steer clear of antitrust laws.

Officials at the CMS and the Office of the Inspector General have also issued a notice on potential waivers that could be granted to ACOs in connection with the shared savings program, and the Internal Revenue Service has issued new guidance for tax-exempt hospitals that are seeking to participate in the program.

The CMS will be accepting comments on the proposed rule for 60 days. The agency also plans a series of open-door forums and listening sessions to explain the proposal and to get feedback from the public.

At press time, the American Medical Association said that it was reviewing the proposed rule and the policy statements from the Federal Trade Commission and the Department of Justice. In a statement, Dr. Jeremy A. Lazarus, the speaker of the AMA House of Delegates, said that ACOs offer “great promise” but that there are still a number of barriers to success, including the large capital requirements to fund an ACO and to make the necessary changes to individual physician practices.

After months of deliberation, officials at the Centers for Medicare and Medicaid Services released a proposed rule outlining how physicians, hospitals, and long-term care facilities can work together to form accountable care organizations and share in the savings they achieve for Medicare.

The voluntary program was created under the Affordable Care Act and will begin in January 2012.

Under the proposal, accountable care organizations (ACOs) could include physicians in group practice, networks of individual practices, hospitals that employ physicians, and partnerships among these entities, as well as other providers. The idea is for ACOs to be a partnership among a range of physicians, including specialists and primary care providers. However, only primary care providers will be able to form an ACO, according to CMS.

According to the proposed rule, providers in the ACO would continue to receive their regular fee-for-service payments under Medicare, but they could also qualify for additional payment if their care resulted in savings to the program.

The proposed framework requires that ACOs meet certain quality standards and demonstrate that they have reduced costs in order to be eligible to share in any savings. The proposal outlines 65 quality measures in five quality domains: patient experience, care coordination, patient safety, preventive health, and care of at-risk and frail elderly populations.

“ACOs aren't just a new way to pay for care; they're a new model for the organization and delivery of the care under Medicare,” said Dr. Donald Berwick, CMS administrator, during a press conference to announce the proposed rule.

Dr. Berwick said he doesn't know how many ACOs will form under the program, but that the level of interest is “enormous.”

Since the Affordable Care Act was passed last year, the health care community has been buzzing about how ACOs might be structured and if they could succeed in reducing health care costs.

Integrated care organizations like Geisinger Health System in Danville, Pa., are considered to have a leg up because their hospital and outpatient care is already coordinated.

But Dr. Berwick said that the proposal allows for ACOs at various levels of development to participate. For example, less-developed ACOs can choose to receive shared savings for 2 years before assuming risk. Organizations that are more matureocan assume risk immediately but be eligible for greater levels of shared savings.

“Our aim is to create on-ramps that will allow many to participate, depending on the different levels of maturity they are starting with,” said Dr. Berwick.

CMS officials estimate that the program could result in as much as $960 million in Medicare savings over a period of 3 years.

Although federal officials said that they expect the coordinated care to pay dividends in savings to Medicare, ACOs will not be set up like HMOs. Medicare beneficiaries will continue to be able to see their choice of providers under fee-for-service Medicare. Providers will be the ones that enroll in ACOs and must notify patients that they are receiving care within an ACO.

In addition to the ACO proposed rule, the Department of Justice and the Federal Trade Commission have issued guidance on how physicians and hospitals that form an ACO can steer clear of antitrust laws.

Officials at the CMS and the Office of the Inspector General have also issued a notice on potential waivers that could be granted to ACOs in connection with the shared savings program, and the Internal Revenue Service has issued new guidance for tax-exempt hospitals that are seeking to participate in the program.

The CMS will be accepting comments on the proposed rule for 60 days. The agency also plans a series of open-door forums and listening sessions to explain the proposal and to get feedback from the public.

At press time, the American Medical Association said that it was reviewing the proposed rule and the policy statements from the Federal Trade Commission and the Department of Justice. In a statement, Dr. Jeremy A. Lazarus, the speaker of the AMA House of Delegates, said that ACOs offer “great promise” but that there are still a number of barriers to success, including the large capital requirements to fund an ACO and to make the necessary changes to individual physician practices.

Federal officials are pouring a $1 billion into a new initiative aimed at reducing hospital readmissions and preventable injuries.

The “Partnership for Patients” brings together physicians, nurses, hospitals, patient advocates, insurers, and employers for a 3-year project that will help spread the lessons of successful quality improvement initiatives across the country and provide tools for health care providers.

Many hospitals have already had success in reducing readmissions or nearly eliminating hospital-acquired infections, but those initiatives have not been adopted widely enough, Health and Human Services Secretary Kathleen Sebelius said at a press conference to launch the Partnership for Patients.

“The challenge is how to figure out how to make these models spread and accelerate this care improvement,” she said.

The goal of the program is to reduce preventable hospital-acquired conditions by 40% compared to 2010 rates by the end of 2013. And officials are also seeking to reduce hospital readmissions within 30 days of discharge by 20% compared to 2010 rates. HHS officials estimate that the quality initiative will save 60,000 lives and up to $35 billion in health care costs, including up to $10 billion in savings for Medicare alone.

The $1 billion investment of federal funds comes from the Affordable Care Act. HHS officials said they were making $500 million available right away through the Community-Based Care Transitions Program to support efforts to improve care transitions between hospitals and physicians in the community. Starting on April 12, hospitals and community-based organizations that team up to provide transition services can submit applications to HHS for funding.

An additional $500 million will become available from the CMS Innovation Center to fund demonstration projects aimed at reducing hospital-acquired conditions.

Under the Partnership for Patients, HHS officials are asking hospitals to focus on nine types of adverse events including drug reactions, pressure ulcers, childbirth complications, and surgical site infections.

Officials at Health and Human Services also plan to recruit a group of “pioneer” hospitals that would seek to improve care for all forms of harm and complications, explained Dr. Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. Dr. Berwick added that these hospitals would go beyond the list of nine conditions set forth and seek to transform themselves into “safer, high reliability organizations.”

“By assembling this partnership and committing to these ambitious goals, we're sending a clear message that we can no longer accept a health care system in which only some Americans get the best possible care,” Ms. Sebelius said.

'We can no longer accept a health care system in which only some Americans get the best possible care.'

Source SEC. SEBELIUS

Federal officials are pouring a $1 billion into a new initiative aimed at reducing hospital readmissions and preventable injuries.

The “Partnership for Patients” brings together physicians, nurses, hospitals, patient advocates, insurers, and employers for a 3-year project that will help spread the lessons of successful quality improvement initiatives across the country and provide tools for health care providers.

Many hospitals have already had success in reducing readmissions or nearly eliminating hospital-acquired infections, but those initiatives have not been adopted widely enough, Health and Human Services Secretary Kathleen Sebelius said at a press conference to launch the Partnership for Patients.

“The challenge is how to figure out how to make these models spread and accelerate this care improvement,” she said.

The goal of the program is to reduce preventable hospital-acquired conditions by 40% compared to 2010 rates by the end of 2013. And officials are also seeking to reduce hospital readmissions within 30 days of discharge by 20% compared to 2010 rates. HHS officials estimate that the quality initiative will save 60,000 lives and up to $35 billion in health care costs, including up to $10 billion in savings for Medicare alone.

The $1 billion investment of federal funds comes from the Affordable Care Act. HHS officials said they were making $500 million available right away through the Community-Based Care Transitions Program to support efforts to improve care transitions between hospitals and physicians in the community. Starting on April 12, hospitals and community-based organizations that team up to provide transition services can submit applications to HHS for funding.

An additional $500 million will become available from the CMS Innovation Center to fund demonstration projects aimed at reducing hospital-acquired conditions.

Under the Partnership for Patients, HHS officials are asking hospitals to focus on nine types of adverse events including drug reactions, pressure ulcers, childbirth complications, and surgical site infections.

Officials at Health and Human Services also plan to recruit a group of “pioneer” hospitals that would seek to improve care for all forms of harm and complications, explained Dr. Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. Dr. Berwick added that these hospitals would go beyond the list of nine conditions set forth and seek to transform themselves into “safer, high reliability organizations.”

“By assembling this partnership and committing to these ambitious goals, we're sending a clear message that we can no longer accept a health care system in which only some Americans get the best possible care,” Ms. Sebelius said.

'We can no longer accept a health care system in which only some Americans get the best possible care.'

Source SEC. SEBELIUS

Federal officials are pouring a $1 billion into a new initiative aimed at reducing hospital readmissions and preventable injuries.

The “Partnership for Patients” brings together physicians, nurses, hospitals, patient advocates, insurers, and employers for a 3-year project that will help spread the lessons of successful quality improvement initiatives across the country and provide tools for health care providers.

Many hospitals have already had success in reducing readmissions or nearly eliminating hospital-acquired infections, but those initiatives have not been adopted widely enough, Health and Human Services Secretary Kathleen Sebelius said at a press conference to launch the Partnership for Patients.

“The challenge is how to figure out how to make these models spread and accelerate this care improvement,” she said.

The goal of the program is to reduce preventable hospital-acquired conditions by 40% compared to 2010 rates by the end of 2013. And officials are also seeking to reduce hospital readmissions within 30 days of discharge by 20% compared to 2010 rates. HHS officials estimate that the quality initiative will save 60,000 lives and up to $35 billion in health care costs, including up to $10 billion in savings for Medicare alone.

The $1 billion investment of federal funds comes from the Affordable Care Act. HHS officials said they were making $500 million available right away through the Community-Based Care Transitions Program to support efforts to improve care transitions between hospitals and physicians in the community. Starting on April 12, hospitals and community-based organizations that team up to provide transition services can submit applications to HHS for funding.

An additional $500 million will become available from the CMS Innovation Center to fund demonstration projects aimed at reducing hospital-acquired conditions.

Under the Partnership for Patients, HHS officials are asking hospitals to focus on nine types of adverse events including drug reactions, pressure ulcers, childbirth complications, and surgical site infections.

Officials at Health and Human Services also plan to recruit a group of “pioneer” hospitals that would seek to improve care for all forms of harm and complications, explained Dr. Donald Berwick, administrator of the Centers for Medicare and Medicaid Services. Dr. Berwick added that these hospitals would go beyond the list of nine conditions set forth and seek to transform themselves into “safer, high reliability organizations.”

“By assembling this partnership and committing to these ambitious goals, we're sending a clear message that we can no longer accept a health care system in which only some Americans get the best possible care,” Ms. Sebelius said.

'We can no longer accept a health care system in which only some Americans get the best possible care.'

Source SEC. SEBELIUS

The medical model of “the more you do, the more you make” is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.

Dr. Colleen Kraft, a pediatrician for Carilion Clinic in Roanoke, Va., has participated in an integrated health system since 2007. The Epic care system links the Carilion Clinic's pediatric specialists with a hospital, therapists, and care coordinators. While participating in an ACO-modeled system, Dr. Kraft said she has noticed a significant improvement in quality of care.

“Our ability to communicate with each other about common patients is extensive and streamlines patient care, especially for children with special health care needs,” Dr. Kraft said. “Parents from all socioeconomic groups are better informed about following asthma action plans, healthy eating, and the importance of prevention. This makes compliance with medications and anticipatory guidance much easier.”

Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).

This year is likely to be a “learning year” for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records.

But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.

Dr. Kraft said it will take more than new technology to make the ACO model a success. “Physicians who choose to become part of an ACO have to want to work more collaboratively. Technology alone doesn't provide better patient care; physicians who take the time to communicate with each other as well as the families improve patient care,” she said.

ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.

Officials at the Centers for Medicare and Medicaid Services released a proposed regulation outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers. An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.

Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings. The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.

The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.

More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-sided risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-sided risk model.

Physicians' groups see pluses and minuses in the government's vision for ACOs.

The ACO model might not allow for pediatricians to capitalize on savings, according to Dr. Virginia Keane of the department of pediatrics at the University of Maryland, Baltimore.

“We already operate in the medical home model. We already have taken on issues of care coordination. The savings made by making those changes, we've already made,” she said. “So if that's the way pediatricians are going to be compensated, what does that mean for pediatrician compensation?” As ACOs are designed to create savings in management of chronic illnesses and decreasing readmission rates, Dr. Keane said most of the savings will go to hospitals, not to pediatricians who handle fewer chronic illnesses.

While she admits the system does seem to work in favor of adult chronic care, Dr. Kraft said the shared savings could still benefit pediatricians. “A pediatric-only ACO could take advantage of savings from hospitalizations (which account for 61% of dollars paid for children with special health care needs). Further savings could come from co-management of chronic illness between primary care and pediatric subspecialties,” she said.

The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn't provide much incentive for small- and medium-sized practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.

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 maintaining 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.

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. 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.

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.”

The NCQA recently concluded testing of its standards with 10 organizations that represent IPAs, multispecialty practice groups, and integrated delivery systems. One issue that came up during the testing is the importance of leadership within the ACO. “We can define structural features that are important for [ACOs], but I think you cannot underestimate the importance of leadership and the cultural change toward patient-centered care in forming these organizations,” she said.

In the first few years, ACOs may come in a variety of forms, according to Dr. Keane. “They're all going to look different and they're all going to figure out different ways to provide care and provide reports. I worry about that,” she said. “First, I think we're going to have years of total chaos. But that's what we've got right now, so it can't be worse.”

The Affordable Care Act also includes a pediatric ACO demonstration project that allows states to award incentive payments through the Medicaid program. That project is also expected to launch next year.

Alicia Ault, Frances Correa, and Naseem Miller contributed to this report.

The medical model of “the more you do, the more you make” is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.

Dr. Colleen Kraft, a pediatrician for Carilion Clinic in Roanoke, Va., has participated in an integrated health system since 2007. The Epic care system links the Carilion Clinic's pediatric specialists with a hospital, therapists, and care coordinators. While participating in an ACO-modeled system, Dr. Kraft said she has noticed a significant improvement in quality of care.

“Our ability to communicate with each other about common patients is extensive and streamlines patient care, especially for children with special health care needs,” Dr. Kraft said. “Parents from all socioeconomic groups are better informed about following asthma action plans, healthy eating, and the importance of prevention. This makes compliance with medications and anticipatory guidance much easier.”

Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).

This year is likely to be a “learning year” for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records.

But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.

Dr. Kraft said it will take more than new technology to make the ACO model a success. “Physicians who choose to become part of an ACO have to want to work more collaboratively. Technology alone doesn't provide better patient care; physicians who take the time to communicate with each other as well as the families improve patient care,” she said.

ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.

Officials at the Centers for Medicare and Medicaid Services released a proposed regulation outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers. An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.

Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings. The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.

The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.

More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-sided risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-sided risk model.

Physicians' groups see pluses and minuses in the government's vision for ACOs.

The ACO model might not allow for pediatricians to capitalize on savings, according to Dr. Virginia Keane of the department of pediatrics at the University of Maryland, Baltimore.

“We already operate in the medical home model. We already have taken on issues of care coordination. The savings made by making those changes, we've already made,” she said. “So if that's the way pediatricians are going to be compensated, what does that mean for pediatrician compensation?” As ACOs are designed to create savings in management of chronic illnesses and decreasing readmission rates, Dr. Keane said most of the savings will go to hospitals, not to pediatricians who handle fewer chronic illnesses.

While she admits the system does seem to work in favor of adult chronic care, Dr. Kraft said the shared savings could still benefit pediatricians. “A pediatric-only ACO could take advantage of savings from hospitalizations (which account for 61% of dollars paid for children with special health care needs). Further savings could come from co-management of chronic illness between primary care and pediatric subspecialties,” she said.

The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn't provide much incentive for small- and medium-sized practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.

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 maintaining 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.

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. 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.

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.”

The NCQA recently concluded testing of its standards with 10 organizations that represent IPAs, multispecialty practice groups, and integrated delivery systems. One issue that came up during the testing is the importance of leadership within the ACO. “We can define structural features that are important for [ACOs], but I think you cannot underestimate the importance of leadership and the cultural change toward patient-centered care in forming these organizations,” she said.

In the first few years, ACOs may come in a variety of forms, according to Dr. Keane. “They're all going to look different and they're all going to figure out different ways to provide care and provide reports. I worry about that,” she said. “First, I think we're going to have years of total chaos. But that's what we've got right now, so it can't be worse.”

The Affordable Care Act also includes a pediatric ACO demonstration project that allows states to award incentive payments through the Medicaid program. That project is also expected to launch next year.

Alicia Ault, Frances Correa, and Naseem Miller contributed to this report.

The medical model of “the more you do, the more you make” is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.

Dr. Colleen Kraft, a pediatrician for Carilion Clinic in Roanoke, Va., has participated in an integrated health system since 2007. The Epic care system links the Carilion Clinic's pediatric specialists with a hospital, therapists, and care coordinators. While participating in an ACO-modeled system, Dr. Kraft said she has noticed a significant improvement in quality of care.

“Our ability to communicate with each other about common patients is extensive and streamlines patient care, especially for children with special health care needs,” Dr. Kraft said. “Parents from all socioeconomic groups are better informed about following asthma action plans, healthy eating, and the importance of prevention. This makes compliance with medications and anticipatory guidance much easier.”

Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).

This year is likely to be a “learning year” for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records.

But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.

Dr. Kraft said it will take more than new technology to make the ACO model a success. “Physicians who choose to become part of an ACO have to want to work more collaboratively. Technology alone doesn't provide better patient care; physicians who take the time to communicate with each other as well as the families improve patient care,” she said.

ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.

Officials at the Centers for Medicare and Medicaid Services released a proposed regulation outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers. An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.

Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings. The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.

The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.

More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-sided risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-sided risk model.

Physicians' groups see pluses and minuses in the government's vision for ACOs.

The ACO model might not allow for pediatricians to capitalize on savings, according to Dr. Virginia Keane of the department of pediatrics at the University of Maryland, Baltimore.

“We already operate in the medical home model. We already have taken on issues of care coordination. The savings made by making those changes, we've already made,” she said. “So if that's the way pediatricians are going to be compensated, what does that mean for pediatrician compensation?” As ACOs are designed to create savings in management of chronic illnesses and decreasing readmission rates, Dr. Keane said most of the savings will go to hospitals, not to pediatricians who handle fewer chronic illnesses.

While she admits the system does seem to work in favor of adult chronic care, Dr. Kraft said the shared savings could still benefit pediatricians. “A pediatric-only ACO could take advantage of savings from hospitalizations (which account for 61% of dollars paid for children with special health care needs). Further savings could come from co-management of chronic illness between primary care and pediatric subspecialties,” she said.

The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn't provide much incentive for small- and medium-sized practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.

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 maintaining 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.

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. 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.

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.”

The NCQA recently concluded testing of its standards with 10 organizations that represent IPAs, multispecialty practice groups, and integrated delivery systems. One issue that came up during the testing is the importance of leadership within the ACO. “We can define structural features that are important for [ACOs], but I think you cannot underestimate the importance of leadership and the cultural change toward patient-centered care in forming these organizations,” she said.

In the first few years, ACOs may come in a variety of forms, according to Dr. Keane. “They're all going to look different and they're all going to figure out different ways to provide care and provide reports. I worry about that,” she said. “First, I think we're going to have years of total chaos. But that's what we've got right now, so it can't be worse.”

The Affordable Care Act also includes a pediatric ACO demonstration project that allows states to award incentive payments through the Medicaid program. That project is also expected to launch next year.

Alicia Ault, Frances Correa, and Naseem Miller contributed to this report.