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Reforming Accountable Care Organizations | Regulatory Review

Experts are exploring opportunities to reduce costs and promote health equity.

According to some experts, the traditional fee-for-service structure used by these programs, in which the government pay providers separately for each particular service rendered, failed provide adequate care to participants. Health insurance being more and more bECOMES unaffordable for taxpayers, the Biden administration has noted it will seek to enact regulations aimed at reducing the costs of health care and expanding access to it. The administration hopes accomplish this in part by encouraging access to Accountable Care Organizations (ACOs).

ACOs are a great example of what is known as a value-based structure of care, where providers are paid based on patient health outcomes for services rendered. COAs are groups of healthcare providers who voluntarily agree to to coordinate providing quality care to Medicare and Medicaid beneficiaries. CO lower health care costs by holding providers collectively accountable for the quality and costs of care provided to their patients.

By replacing traditional fee-for-service systems, ACO models are meant to to improve efficiency and equity by reducing unnecessary expenditure and setting payments according to the needs of the population. In 2018, the Centers for Medicare and Medicaid Services (CMS) published a final rule which encouraged ACOs to increase their savings and accelerate the transition to value-based models of care. These models, however, also require COAs reimburse the government if spending exceeds their target. As a result, many ACOs abandoned of the CMS program when their costs increased.

In response, CMS recently announcement plans to modify Medicare-sponsored ACO programs with the goal of improving system efficiency and promoting health equity. Proposed changes objective to broaden participation, minimize the financial risk accumulation of COAs, and equalize access to health care services. The Model ACO REACHa pilot program starting on January 1, 2023, test Fairness enhancement features to improve ACO delivery performance.

Despite the potential of ACOs to bridge the chasm between CMS aspirations and realities, healthcare providers report focused towards difficulties in implementing COAs. Critics argue that the ACOs hinder the quality of care and fail to reduce costs adequately. But others resistant Hopefully, with a few tweaks, CCOs can still deliver on their promise to improve value-based care. While the ACO controversy lingers, CMS is still trying find ways to salvage his responsible care ideal of reducing health care costs and improving the quality of care.

At this week’s Saturday seminar, academics discuss whether ACOs have fallen short of their goals and how regulatory reforms could improve their performance.

  • CMS should build on empirical findings of ACO performance over the past decade to expand access to high-quality, low-cost health care, argue Todd Zigrang and Jessica Bailey-Wheaton of Health capital consultants in a article Posted in The health advocate. The U.S. Department of Health and Human Services’ Office of the Inspector General conducted a study in 2019 of 20 high-performing ACOs who, Zigrang and Bailey-Wheaton combat, CMS can use to guide future regulatory reforms. Based on the findings of the report, Zigrang and Bailey-Wheaton conclude that CMS should issue new regulations requiring ACOs to develop strong primary care programs that provide comprehensive, patient-centered care, reduce costs and improve the quality of care.
  • In a study Posted in The American Journal of Managed Care, Nate C. Apathy of the University of Pennsylvania Perelman School of Medicine, Jay Holmgren of University of California, San Franciscoand Rachel M. Werner of the University of Pennsylvania The Leonard Davis Institute of Health Economics explains that COAs aim to improve coordination between individual healthcare programs, but they often fall short of this goal. Apathy, Holmgren and Werner found that participation in the ACO increases the exchange of health information between providers, but that this effect depends on the density of ACOs in a particular market. Apathy, Holmgren and Werner conclude that policymakers should more directly regulate data sharing to facilitate ACO coordination, as the US Department of Health and Human Services has done before under the 21st Cures of the Century Act by creating new centers to coordinate and accelerate the development of medical products.
  • In a study Posted in Population Health Management, Brandon W. Yan of the University of California, San Francisco School of Medicine and several co-authors distinguish between urban and rural ACO adoption rates. They combat that while CBOs have grown steadily across the country, organizations in rural areas face unique training and participation challenges. An analysis of relevant market factors, including physician concentration, Benefit of Medicare commercial insurance coverage and purchase—revealed that ACO presence is more likely to be in urban areas with lower physician concentrations and moderate Medicare Advantage participation. Yan’s team Explain that national regulations should promote COA models that reduce barriers to participation for rural providers.
  • Despite continuous efforts to integrate into their various programs social determinants of healthsuch as education and economic status, Medicaid ACOs currently have limited means to achieve these goals, according Genevra F. Murray of Boston University School of Medicine, Hector P. Rodriguez of the University of California, Berkeleyand Valerie Lewis of the Gillings School of Public Health at the University of North Carolina. In a study Posted in Health Affairs, they sampled 22 ACOs to assess the state of social service integration. Murray, Rodriguez and Lewis conclude that barriers to integration will persist unless CMS releases guidelines on how Medicaid dollars can be used for non-medical programs and incorporates spending requirements for social needs.
  • In a article in The Milbank Quarterly, Stephanie M. Kissam of RTI International and several co-authors evaluate CMS State innovation model, which provided six states with a total of $250 million to test regulatory innovations aimed at moving to value-based models of care, such as ACOs. States regulate their health care systems by providing oversight of health insurers, medical professionals and health insurance products, according to the Kissam team. They found certain policy levers have been shown to be consequential to a state’s performance: participation forced by state law, regulation of insurers to require investments in primary care, and minimum expenditures required for exchange of health information systems. The Kissam Team concludes that the regulatory action of the State obliging the actors of health to reform the existing practices promotes the change of the health system more effectively than the financial investments.
  • According Marilyn Uzdavines of Nova Southeastern University in a article Posted in Texas A&M Law Review. Uzdavins suggests which changes to Rigid law, a federal law that prohibits the referral of physicians to health care entities when there is a financial relationship between the referring physician and the entity, could improve the cost and quality of care. By clarifying key terms, changing technical requirements leading to inadvertent non-compliance, and creating a new value-based exception for ACOs, a reformed Stark Act can help address legal barriers to improved delivery. health care, argue Uzdavins.

The Saturday Seminar is a weekly feature that aims to put into written form the type of content that would be conveyed in a live seminar involving regulatory experts. Every week, Regulatory Review publishes a brief overview of a selected regulatory topic and then summarizes recent research and academic writing on that topic.

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