The Trump
administration is proposing to restrict an innovation in the Affordable Care
Act that was intended to improve Medicare and slow spending in the vast federal
insurance system for older Americans. Health-care researchers have hailed the
model’s promise to improve quality and efficiency, but government data suggest
it is not saving enough money.
The changes,
announced Thursday by the administrator of the Department of Health and Human
Services’ Centers for Medicare and Medicaid Services, would significantly
curtail Accountable Care Organizations. The ACOs can be teams of doctors,
hospitals or other providers who become responsible for all the health-care
needs of a specific group of patients.
Under the ACA, these
teams have choices about their financial arrangements with the government. They
can either collect bonuses if they provide better care at lower cost than the
regular Medicare program, or they can collect greater amounts if they also are
willing to accept the risk of owing money in case they end up overspending.
More than 80 percent
of 561 teams in this Medicare Savings Program are using the bonus-only version,
with more than 300,000 clinicians and 10 million patients taking part. Now,
federal health officials want to limit such teams, saying federal data show
that this version has ended up costing Medicare extra money.
Until now, ACOs have
been allowed six years in which they can take part without assuming
responsibility for potential losses. The proposed rule changes would limit that
to two years.
“We believe the time
has come to put accountability into the Accountable Care Organizations,” CMS
Administrator Seema Verma said Thursday in a conference call with journalists.
She said it was “a shocking reality” that four-fifths of these teams have been
unwilling to shoulder financial risk in the program so far.
Verma repeatedly
dodged questions about how the change would influence the number of ACOs
participating in Medicare.
But a 607-page
proposal in the Federal Register predicts that 109 fewer such organizations
would be part of Medicare within a decade. And according to CMS figures, nearly
300 ACOs have already been in the bonus-only version of the program for two or
more years — so would have to switch or drop out after a six-month grace period
next year that CMS envisions.
Among some
health-care researchers, this version of managed care, run by physicians or
hospitals instead of insurers, have been held out as a bright light for improving
both the quality and efficiency of the United States’ notoriously expensive
health-care system. The government conducted early experiments before the ACA
was passed in 2010, with mixed results.
In 2012, an expansion
of Medicare ACOs became one of the first broad
changes to the delivery of care to flow from the sprawling —
and politically polarizing — law.
In an interview
Thursday, Donald M. Berwick, who led CMS during part of the Obama
administration, said, “ACOs are a really important component of a fleet of
major experiments this country is doing to shift” the payment of medical
services from how much is delivered to the value of the care. But he added,
“it’s a fragile experiment” and that changes that lead to “a chilling of
interest” in teams participating “may be the wrong direction.”
Clif Gaus, president
of the National Association of ACOs, said the proposal “is really upending . .
. a program that is showing savings and huge quality improvements.” Gaus said
that CMS’s forecast significantly understates how many would drop out, saying that
a recent survey of its members showed that 70 percent would leave Medicare.
“That’s the
disaster,” he said.
Under current rules,
ACOs tell patients at the end of a year that their primary-care doctor is part
of such a team. Verma said that the new rules also would require patients to be
sent written notices, but not before choosing a physician.
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