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ACO Industry Stakeholder ‘Outrage’ | Theatrics or Substance?

By Gregg A. Masters, MPH

Re-framed title: ‘CMS, ACO’s and ‘The Grapes of [special interests] Wrath?’

In the United States of Amnesia (“USA”), we seem to be drawn to a regular if not somewhat addictive ‘blame game’ pastime.  Watching the post ACO Notice of Proposed Rule release commentary, and subsequent update by CMS announcing the fast track roll-out options of The Pioneer Program, et al, I am reminded of the

Success has many fathers but failure is an orphan quote.

As a veteran of the managed health care industry dating back to PSRO’s and HSA’s (no, not health savings accounts),  I can say we are dangerously close to, if not directly enmeshed in a Shakespearean ‘Much To Do About Nothing’ moment.

I will not line item the pro v. con arguments of the rule’s relative merits or liabilities, nor its subesequent updates (in direct response to active healthcare industry stakeholder input), but outline what seems to me to be the core heartburn of CMS’s ‘over-reeach’ (at least in the eyes of some).

As context my lens includes the comments filed to CMS, many of which are proffered from the point of view of providers/suppliers & channel partners, v. those of us on the consumer or patient experience side.

So bottom-line, other than the excessive cost burden imposed (CMS estimates typical start-up costs to be somewhere in the $1.8 million range), the real issue boils down to putting patients or consumers in the conversation or at the table, via ‘shared governance’ and CMS’s indicia of ‘patient-centeredness’. For an excellent recap by David Harlow at e-patients.net, click here.

Stay with me for a moment, just imagine this scene: a board meeting of a private (v. federally qualified anything) single or multi-specialty medical group, IPA, super IPA, or emerging managed physician network, MSO, etc., convenes for a regular ‘business meeting’. On the agenda are standing considerations: production trends, gross charges, adjustments, net collections, payor mix, utilization, resource management, etc., as well as quality issues, including patient satisfaction, reportable metrics, clinical pathways, as well as market competitive developments,  hospital affairs, and the general welfare of the practice or network. But at this meeting something is different. There is now a consumer or patient representative in the conversation as ‘principal’.

Will the conversation be different with a patient ‘in the room’ with theoretical equal standing in the conversation? Have you ever seen how a problem is discussed by professionals when a ‘skin in the game’ participant is in the room, both observing and participating in process? I have, and in my experience the quality, intensity and urgency of problem solving is typically in a fast track if not real time resolution mode.

So other than AHIP’s and AHA’s grievances of prospective exclusion from ACO formation, organized medicine’s concern about capital and start-up costs, as well as potential CMS overkill in everything from marketing materials, to indicia of a patient center entity, the real issue seems to be the intention of CMS to get the healthcare industry to ‘walk the talk’ with respect to known solutions to the continued healthcare conundrum.

Just sayin’… so, what did I miss? Any thoughts?

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