December 3, 2010
Dr. Don Berwick
Administrator
Centers for Medicare and Medicaid Services
Room 445-G Hubert Humphrey Building
200 Independence Ave. SW
Washington, DC. 20201
File Code: CMS-1345-NC
Dear Dr. Berwick:
The undersigned members of the Campaign for Better Care appreciate the opportunity to
comment on the CMS Request for Information pertaining to the Accountable Care
Organizations, published in the Federal Register, vol. 75, no. 221, pages 70165 to 70166.
The Campaign for Better Care is a broad-based coalition of consumer organizations with a
direct stake in improving the health and quality of life for older adults with multiple health
conditions and their family caregivers. We are committed to ensuring that new models of
care delivery and payment, including Accountable Care Organizations (ACOs), provide the
comprehensive, coordinated, patient- and family-centered care that individuals want and
need.
The stakes for ACOs are very high. There is incredible pressure for this new care model
to deliver on the promise of better outcomes and lower costs. While some stakeholders
are concerned about asking too much of ACOs, we believe that they must be held to a
standard that is high enough to ensure they both improve care for patients and lower
costs. If the bar is set too low, ACOs will likely fail.
We appreciate CMS seeking input on some key design issues prior to development of the
ACO proposed rule. Our comments address several of the questions you raise.
Small Practices
Regarding small physician practices and access to capital, we believe that ACOs should
be built on a foundation of comprehensive, patient-centered primary care. We understand
the resource constraints many small practices face but CMS should not set a lower bar for
these providers because so many patients depend on them to deliver coordinated, patient__________________________________________________________________________________________
1875 Connecticut Avenue, NW, Suite 650
Washington, DC 20009
P 202.986.2600
F 202.986.2539
E [email protected]
W www.CampaignforBetterCare.org
The Campaign for Better Care is led by the National Partnership for Women & Families, Community Catalyst, The
Leadership Conference on Civil and Human Rights, and the National Health Law Program – and funded by The Atlantic
Philanthropies.
centered care. Instead, we believe that CMS should incentivize ACOs to play a major role
in supporting changes in the way these practices deliver care. ACOs can offer physician
practices important resources, including infrastructure and technical assistance with
practice redesign, to accelerate their progress. Further, risk adjusted payment for complex
patients, as well as potentially additional incentives targeted to small practices would play
a major role in supporting these clinicians as they care for patients that require more
comprehensive care and services.
Beneficiary Attribution
The RFI asks for input on how, and at what point, beneficiaries should be attributed to an
ACO and whether prospective or retrospective attribution is more appropriate.
The Campaign believes that there must be full transparency of beneficiary attribution and
enrollment in ACOs. Beneficiaries have a right to know about any new financial incentives
that may influence provider behavior and the care that is delivered. And the only way to
provide full transparency is through prospective enrollment. Retroactive “reconciliation”
may be a potential option if there are unexpected changes in the risk pool in a given year
but beneficiaries should always know in advance of their participation in an ACO. We also
believe that beneficiary attribution should not result in any interruptions in care that create
significant hardships for beneficiaries or leave negative impressions, such as limiting care,
that cause beneficiaries to reject ACOs outright.
Prospective transparent attribution must include clear beneficiary notification.
Beneficiaries need to know what they can expect from the ACO including the attributes
that differentiate the ACO from the current fee for service model like improved care
coordination and the expectation of better quality care. Notification should also include
information about providers in the network, beneficiary rights and responsibilities including
the option to seek care outside the network, and information about who to contact when
their expectations are not being adequately met. If beneficiaries perceive they are being
“locked in” to a new system without their knowledge or consent they are very likely to reject
the new system out of hand. Written notification should be provided no later than the
patient’s first appointment with an ACO provider and available at least annually on an
ACO’s website. The beneficiary notification is critical and CMS should consider providing
a model notice based on research with patients and families and developed with significant
consultation and input from consumer groups.
There has been some discussion within the policy community of the appropriateness of
creating incentives for beneficiaries to remain in the ACO network. Positive incentives for
beneficiaries to remain in ACOs providing the highest quality, highest value care may be
worth exploring. But we strongly oppose any financial penalties for beneficiaries who seek
care outside the ACO network as there may be many legitimate reasons for doing so especially during the period when we are testing models and learning what works. Most
importantly, consumer organizations and patients themselves should be directly consulted
in the design of such approaches.
We urge CMS to consider all of the factors that influence a beneficiary’s decision to seek
care outside a health care network. As ACOs are evolving and building their networks
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there may be very appropriate reasons for beneficiaries to seek certain kinds of nonnetwork care. For instance, a beneficiary may have a long-standing relationship with a
physician not yet in the ACO network. Or they may need a type or quality of care not
available in the ACO. This is an area where testing and rapid learning will be critical and
where we must stay focused on keeping the patient’s interests primary. The balance we
strike should be one that results in better patient care and care experience, better patient
outcomes, and lower costs. If ACOs achieve these goals they won’t have a hard time
keeping patients in their network.
Finally, since most beneficiaries tend to choose and stay with a plan in which their doctor
participates we believe one of the strongest incentives for beneficiaries remaining in an
ACO will be the adequacy of the network and the improved quality and coordination of
care. A robust network of primary care and specialists will help to ensure that a
beneficiary doesn’t have to “shop around” outside the ACO. Another strong indicator is
positive patient experience. As such, measurement, improvement, public reporting, and
payment for patient experience survey results are critical.
Assessing Beneficiary/Caregiver Experience
The RFI is seeking guidance on how it should assess beneficiary and caregiver experience
as part of its assessment of ACO performance.
The Campaign strongly believes that patient and caregiver experiences of care are “core
capabilities” that are directly linked to the success of an ACO. Patient reported measures
of care experience and outcomes should be the key indicators of how well care is being
delivered. This is particularly true for patients with multiple chronic conditions, for which
patient reported measures of experience and outcomes may be the best proxies we have
for many other types of clinical performance measures. Caregiver experience is also
critical to gauge the care for those patients with cognitive impairments that prevent them
from talking about their own experience. Caregiver experience can also provide insights
into areas patients themselves may be reticent to discuss.
CMS should require use of validated tools like CAHPS surveys that capture patient
experience of care and allow for comparison, trending, and provider incentives. But these
surveys should also be further evolved to capture the unique attributes of care in ACOs.
Just as there is now in development a specific CAHPS survey for medical homes, a similar
effort should be undertaken for ACOs. Further, the methodology for the survey should be
updated given the advancements in technology (internet, mobile applications, etc) we have
seen in the past 15 years. Finally, ACOs should examine patient experience data by race,
ethnicity, gender, preferred language, and disability status, and be incented to use those
results to improve. This will move ACOs forward in the drive to reduce and eliminate health
disparities.
There should also be a requirement for ongoing solicitation of qualitative information about
patients’ care experience by individual providers to improve their care practices and better
engage their patients and family caregivers. CMS should support ACO use of activities
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like patient and family advisory councils, focus groups, and patient walk-throughs as
means of collecting qualitative information on a more real-time or ongoing basis.
Overall, ACO criteria should require the use of patient reported measures to assess patient
outcomes and functional status. There is nothing more important than using patient
reported measures of experience, outcomes, and engagement to genuinely affect the
quality and value of care being delivered by ACOs. Many tools and methods currently
exist and could be used immediately. For instance, tools like How’s Your Health?,
developed by Dr. John Wasson of the Dartmouth Medical School is designed to help
patients take better care of themselves while at the same time engaging patients and
physicians in a closer working relationship. Additional tools and measures must also be
developed. Consumer organizations are ready to work with CMS to identify and promote
the implementation of the best tools and strategies. And these measures and tools should
be linked to significant portions of ACO payment incentives.
This is an important area for CMS, AHRQ, and the Innovations Center to invest resources
for rapid development and testing of tools and measures that will enable us to assess and
improve care experience and outcomes from the perspective of patients and family
caregivers, as well as better engage patients and caregivers in the management of their
care and health.
Patient Centeredness Criteria
The RFI asks for input on aspects of patient-centeredness that are particularly important
for CMS to consider. Ensuring that new models like ACOs are providing genuinely patientcentered care is paramount. If changes in payment and delivery are perceived as primarily
benefiting health plans, providers, and Medicare there is a high probability that patients will
see them as ineffective at best, and contrary to their interests at worst.
We list below a number of key patient-centered criteria based on a tool the Campaign and
its members developed for evaluating new models of care. The full “yardstick” tool can be
found in Appendix A.
~ Individualized care plans that reflect the patient’s personal goals are developed in
collaboration with the patient and authorized caregiver;
~ Where appropriate, comprehensive geriatric assessments, including use of risk
assessment tools and the evaluation of physical, emotional, social and functional
capacity, are conducted;
~ Where appropriate, assessments of caregivers’ needs are conducted;
~ An interdisciplinary care team is established and meets regularly;
~ Care team conducts ongoing clinical monitoring, patients and caregivers are
contacted periodically, and beneficiary advance directives are kept up-to-date;
~ Patient decision tools are used to guide shared decision-making by
patients/caregivers and practitioners;
~ Patient information and medical history are current and available to the care team
and patient and family caregiver;
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~ Processes are in place to effectively monitor and manage all tests, referrals, and
procedures;
~ Medications are actively managed and reconciled to avoid adverse interactions;
~ Patient care transitions are planned, managed, and tracked, using appropriate tools,
such as transition checklists, medication reconciliation, and care plans;
~ The needs of patients with physical or cognitive limitations, language or cultural
differences, and other issues that could impede access to care are identified and
accommodated;
~ Care team connects the patient and caregiver with community-based support
services, as needed;
~ Care team is available by phone, email, or in-person during evenings and
weekends, and in-office appointments are scheduled promptly; and
~ Ongoing assessments of care coordination strategies are conducted and plans for
improvement are implemented, as needed.
Quality Measures
The RFI is also seeking guidance on what quality measures the Secretary should use to
determine performance.
The Campaign believes that a core set of measures would help assure Medicare that the
ACO is doing its job and help assure beneficiaries that they are receiving high quality care.
CMS should include the following types of measures as part of a core set:
patient reported measures of experience, outcomes, and engagement;
individual and population-based outcomes and functional status;
care coordination (especially for hospitalizations, transitions, and medication
management);
cost, resources use, efficiency, and appropriateness;
cross cutting measures which are especially important to patients with multiple
complex, chronic conditions;
safety measures; and
measures relevant to high prevalence/high impact conditions.
Measures collected and reported should be stratified and reported by race, ethnicity,
primary language, disability status, and gender to facilitate reductions in health disparities.
And to better assess and compare across ACOs, the core set of measures should be
monitored and reported by all ACOs.
Finally, ACOs should also be required to annually publicly report performance information
to patients as well as providers. The information for patients should be clearly presented,
with explanations for how to interpret the information. Materials should be provided
electronically and hard copies should be made easily available to patients/caregivers
without access to the internet.
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Additional Payment Models for Consideration
The RFI asks whether other ACO payment models should be considered in addition to the
shared savings arrangements provided in Section 1899(d).
The Campaign encourages CMS to be open to exploring a variety of payment models for
ACOs as long as the models improve the quality and delivery of care for patients.
Under the “bonus only” savings model now being considered ACOs have very little to lose.
ACOs that lower health care spending would share in a portion of those savings. Those
ACOs that maintain the current level of spending or increase costs may not receive a
bonus but their underlying payment isn’t affected so there is minimal incentive to change
care delivery and reduce costs. Over time a bonus only model may generate fewer
savings.
Other options – like those put forth by Dr. Robert Berenson of the Urban Institute and the
Medicare Payment Advisory Commission (MedPAC) – would allow the ACO to share in
some portion of savings if costs were lowered but would also put the ACO at some
financial risk if spending increased over a target amount. We believe it is worth
investigating these other kinds of options so long as the beneficiary remains protected.
Quality of care is a paramount consideration of patients.
And finally, we strongly recommend that beneficiaries share in a portion of the shared
savings. CMS should also consider options that would reinvest a portion of the savings
into improving coverage.
Conclusion
Thank you for the opportunity to comment on the RFI. We know that CMS is doing a
tremendous amount of work as you prepare to draft the proposed regulations for ACOs
and we appreciate the opportunity to provide the consumer perspective. If you have any
questions regarding our comments, please contact Kirsten Sloan at
[email protected] or (202) 986-2600.
Sincerely,
Action for Children North Carolina
Advocacy for Patients with Chronic Illness, Inc.
Alzheimer’s Association
American Cancer Society Cancer Action Network (ACS CAN)
American Hospice Foundation
Center for Medicare Advocacy
Coalition of Wisconsin Aging Groups (CWAG)
Community Catalyst
Consumer Health Coalition
Consumers for Affordable Health Care
Easter Seals
Families USA
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Family Caregiver Alliance
Health Care for All (MA)
Maine Council of Senior Citizens
Medicare Rights Center
National Alliance for Caregiving
National Council of Jewish Women
National Health Law Program (NHeLP)
National Osteoporosis Foundation
National Partnership for Women & Families
National Women's Health Network
NC Justice Center’s Health Access Coalition
Ohio Alliance for Retired Americans
Service Employees International Union (SEIU)
The Empowered Patient Coalition
UHCAN Ohio
Well Spouse Association
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APPENDIX A
A “Yardstick” for Better Care
Elements of Patient-Centered Practice for Inclusion in
New Models of Care
Understanding patients’ and caregivers’ needs and preferences
~ Individualized care plans that reflect the patient’s personal goals are developed in collaboration with
the patient and authorized caregiver;
~ Where appropriate, comprehensive geriatric assessments, including use of risk assessment tools
~
~
~
and the evaluation of physical, emotional, social and functional capacity, are conducted;
Where appropriate, assessments of caregivers’ needs are conducted;
Care team conducts ongoing clinical monitoring, patients and caregivers are contacted periodically,
and beneficiary advance directives are kept up-to-date; and
Patient decision tools are used to guide “shared decision-making” by patients/caregivers and
practitioners.
Care coordination and management
~ An interdisciplinary care team is established and meets regularly;
~ Patient information and medical history are current and available to the care team and patient and
family caregiver;
~ Processes are in place to effectively monitor and manage all tests, referrals, and procedures;
~ Medications are actively managed and reconciled to avoid adverse interactions;
~ Patient care transitions are planned, managed, and tracked, using appropriate tools, such as
transition checklists, medication reconciliation, and care plans;
~ The needs of patients with physical or cognitive limitations, language or cultural differences, and
other issues that could impede access to care are identified and accommodated;
~ Care team connects the patient and caregiver with community-based support services, as needed;
~ Care team is available by phone, email, or in-person during evenings and weekends, and in-office
appointments are scheduled promptly; and
~ Ongoing assessments of care coordination strategies are conducted and plans for improvement are
implemented, as needed.
Clinical outcomes and continuous quality improvement
~ Any new delivery system pilot program or payment model should include ongoing assessment of
~
~
~
~
clinical quality, appropriate public reporting, and implementation of continuous quality improvement
programs;
Robust clinical performance measures should be used to evaluate care delivery across the care
continuum, and such evaluation should move quickly from today’s generation of measures to
encompass patient-centered outcome and experience measures;
Performance assessment should include: measures of clinical quality patient outcomes, care
coordination, avoidable hospitalizations, readmissions and ER use, adverse drug interactions, and
resource use;
Any new delivery system pilot program or payment model that creates new provider financial
incentives should calculate rewards by weighing both quality measures and cost-savings;
Race, ethnicity, primary language and gender data are collected and used to identify and eliminate
disparities.
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Patient/caregiver engagement and experience of care
~ Patient and caregiver experience is evaluated frequently through patient surveys and the results are
used both to improve quality and to inform patients and caregivers;
~ Aid is provided to help and support patients and caregivers in managing their conditions;
~ Provider performance on patient and, where practicable, caregiver experience of care surveys is
used in calculating any provider financial rewards under new pilot programs or payment models.
Accountability
~ Patients are notified of providers’ and facilities’ participation in any delivery reform pilot program or
~
~
~
~
~
new payment model, including disclosure of any provider or facility financial incentives or shared
savings opportunities;
Patients are clearly informed of the opportunity to opt-out of any pilot program or new payment
model;
An external appeals process is available to patients whose providers or care facilities are
participating in a pilot program or new payment model that offers providers/facilities the opportunity
to profit from the savings generated for the Medicare program;
The methodology for determining provider/facility payment under any delivery reform pilot program or
new payment model should include risk adjustment to reflect differences in health status among
Medicare beneficiaries;
Before any pilot program is expanded to a broader population, a comprehensive, independent
evaluation of quality and cost outcomes should be conducted, and its design should include
comparison groups with similar demographic make-up located in areas with similar Medicare
spending growth rates; and
Decisions about expanding pilot programs, and the evidence to support the decision, are transparent
and there should be opportunity for public comment to inform this decision-making.
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