Pioneers Move Forward, But Medicare May Still Be Left Behind on ACOs

A CMS official announced Tuesday that final regulations for the Medicare Accountable Care Organization (ACO) Shared Savings Program are now expected mid-October.  It looks like ACA’s requirement that the SSP launch January 1 is now out of reach, and there’s scuttlebutt here in DC that the launch date will be pushed to June or July 2012.  These regs can’t come fast enough — and must be dramatically redrafted from the disastrous April draft — or Medicare could be left behind as the ACO revolution surges just about everywhere else.

Sure, the Pioneer ACO Demonstration was some progress, especially on the beneficiary alignment provisions and the apparent willingness of CMS to consider our partial capitation proposals.  All 6 of GHG’s applicants for Pioneer made it to the finals this week, advancing both partial (Part B only) and global (Parts A and B capitated, excluding transplants and ESRD) capitation models.  CMS intends to pick 25-30 Pioneer ACOs to launch on January 1 — these are the advanced “already ACOs” that are ready to go given their significant integration and deep experience in Medicare Advantage — and they’ll give CMS some early wins to tout to a skeptical Congress.  We are thrilled all of our Pioneers are moving forward — with no arrows in their backs yet.

But it’s the Shared Savings Program with its applicability to a much broader swath of providers that’s significant here — and that messy draft reg from last spring was like a cold shower from Medicare for most providers that might consider it.  The irony is the draft regs forced many sophisticated provider systems and medical groups to recommit themselves to Medicare Advantage.  CMS got over 1,200 comments on the NPRM and we’re hopeful next month’s final reg gets it right. 

The ACO train is leaving the station in both the Medicaid and commercial markets, and Medicare must be on it if there’s to be any hope of significant delivery system reform.  Take for example the following initiatives being undertaken by the major payers:

• United Health Group has 1 ACO in Tucson and expects to expand to 9-13 this year
• Aetna is in more than 100 conversations about building ACOs and is actively marketing ACO back end operations functions to providers
• Centura is developing a strategy to market ACO development and operations support functions and is pursuing several ACO pilots in the commercial market
• Cigna has ACO experiments in 12 markets expanding to 30 by year end 
• Humana is in discussions to develop ACOs in several of its markets, especially FL and AZ
• Wellpoint is partnering with major medical groups to establish ACOs
• Coventry is creating ACO models and may roll them out first in support of its Medicaid diversification strategy
• HealthSpring has committed to a major ACO development initiative with its major provider groups and clinics its acquired in the Bravo transaction

We’re crossing our fingers that our friends in the CMS Innovation Center took those 1,200 comments to heart and that we’ll see a viable final reg on ACOs next month.  Broad participation in Medicare by ACOs would be another tremendous achievement to add to the legacy of Dr. Berwick.