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Wal*Mart: RFI ‘Overwritten and Incorrect’

By Gregg A. Masters, MPH

Whoa! Not 24 hours after the Request for Information (RFI) issued by WalMart Health and Wellness directed to it’s ‘strategic partner’ downline hit the street, I mean was leaked to the press, WalMart’s senior management felt compelled to promptly backdown from it’s rational, comprehensive, timely and sensible approach to make a meaningful dent into the US Healthcare, I mean, ‘Sickcare’ quagmire, by issuing the following terse statement:

Walmart Statement in Response to Health & Wellness Request for Information

“The RFI statement of intent is overwritten and incorrect. We are not building a national, integrated, low-cost primary care health care platform.”
– John Agwunobi M.D., Senior Vice President & President of Walmart U.S. Health & Wellness

Yikes! What’s behind this ‘whiplash’ effect?

It’s not news that WalMart has a mixed history with respect to the way they manage or evade (depending on your point of view) offering health benefits as an incentive to their less than full time staff. Yet, WalMart is the ‘400 pound gorilla’ as Chukwuma I. Onyeije, M.D., aka @chukwumaonyeije opined in a Google+ thread to a pool of health care social media peeps on Wednesday.

Regardless of the creative health benefits offer or ‘avoidance strategy’ for their part time staff, WalMart who’s gross sales account for approximately .5% of total US GDP, is a behemoth and perhaps second only to the Federal Government, the single largest ‘wholesale buyer’ of health benefits in the US.

So when they retained Price Waterhouse Coopers to consult on the compiling and distribution of an RFI to the tighly held ‘strategic partner’ network, they clearly intended to step into the population management fray of the payor/provider conundrum. You know, your costs are my revenues…

I’ve suspected all along, that while many on the provider side whine about CMS, the PPACA and now final rule to implement ACOs, many forward thinking peeps, mostly the Wall Street crowd who smell profits in those emerging re-engineered rules around population health management are stepping foward, perhaps aided and abetted by the so called ‘2nd in position skin in the game’ employer community.

We’ll watch and report with interest how this drama and retraction plays out.

See recent article released today by NPR, ‘Wal-Mart’s Clarification on Health Care Leaves Room For Big Moves‘.

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#occupyhealthcare: Hype or Hope?

By Gregg A. Masters, MPH

Sunday, November 6th 2011 may mark a tipping point in the weak-tied and ‘talk is cheap‘ happy talk often characteristic of episodic and even planned healthcare social media conversations. While a dedicated and passionate community mostly focused on learning, defining, sharing best practices and what constitutes the ‘meaningful use’ of this emerging communications and community building media, there is no consensus of what the social media value proposition is or should be in healthcare. Is it marketing, customer service, stakeholder data mining, more effective messaging and engagement; or is it about transformation of a house of cards, on the verge of implosion dysfunctional sick care enterprise?

In my view and as I tweeted on the front end:

‘If you’re not about the business of transformation, you are taking up too much bandwidth.’

Editor’s Note: If social media is to create ‘real value’, then it must be able to tame the beast aka ‘the healthcare borg’ or ‘conundrum‘ that passes for the American healthcare system today.

Context for the Tweetchat could be found in the blog post titled: The Fatal Flaw in American Healthcarewhich among other indicia include the spiraling cost of health insurance and ‘diminishing returns’ nature of the benefits offered, the unsustainability of the premium trend trajectory even with the massive cost shifting underlying the health plan industry’s evolving underwriting gimmickry, the number of uninsured, growing pools or ‘under-insured’, on and on.

So on a day when the tribe would usually assemble for a #hcsm conversation, the room was full of healthtweeps who wanted to register their concern for, interest in, and intention to be part of a process that generally would pivot the conversation and perhaps action in a direction to remedy some if not all of these admitted ‘flaws’.

What followed was a barrage of Tweets, but those stats are summarized as follows:

Number of Tweets: 1935
Average Tweets per Hour: 74.42
Number of Participants: 317
Average Tweets per Participant: 6.1

The actual transcript from the TweetChat can be accessed here.

So what’s this got to do with ACO, accountable care and health reform? I float a point of view in my next post.

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Dr. Don Berwick on ACO’s: From Volume to Value

By Donald Berwick, MD

Editors Note: Thanks to a tweet today via @AxSys_Health

CMS Administrator Don Berwick, M.D., explains ACO’s in plain language.

Hi, I’m Don Berwick, CMS administrator. Today’s a kind of red letter day, October 20th 2011. That’s the day in which we launch the Accountable Care Organization final rule and I just want to spend a minute describing this to you a bit.

This is one of the most exciting and important elements the Affordable Care Act. When we think about the goal of transforming American medicine into the kind of care that we all want for ourselves and our loved ones. American medicine is fragmented right now.

You get lost between the slats because we built the system that way, we pay for it that way, we train for it that way and institutions manage themselves separately. That’s not what patients need. That’s not what you want and I want. We want continuity and seamlessness and most of all we want to stay home and healthy instead of being in hospital beds or sick if we can avoid it.

We are trying now through all the policies in the Affordable Care Act to change the structures of incentive in support for the American health care system, so we can better support that seamless care. Right now in a fragmented payment system hospitals get rewarded, for example, for keeping their beds full. Doctors get rewarded for doing as much as they can. We’re, shifting that game. It now becomes not how much you do but how well you do, that determines the rewards you get and the support you get from us at CMS.

That’s really what doctors and nurses and hospitals want to do anyway. What’s the idea behind an Accountable Care Organization, is to set up a structure, in which doctors and hospitals and others can join together and take responsibility for a group of patients, Medicare beneficiaries, who are attributed to them.

We watch the beneficiaries, we watch where they get their care and if they get the majority of their care from a group of doctors who want to form an ACO then those patients are attributed to the ACO. They still can go anywhere they want, it’s still a Medicare fee for services to the patient lost no choices. But now that ACO conformance say we want to take responsibility for these people that come to us for care, as the ACO then begins to better coordinate care for those people building more cooperation, investing in care coordination, adopting electronic records, working in such a way that people can stay out of the hospital and stay healthy.

What will happen is cost will fall and quality will go up and now in the Accountable Care Organization world they can share in the savings. We split the savings with them. Medicare keeps some, some goes back to the providers of care We don’t want them skimping on care and so we watch quality very closely. The ACO rule has in it 33 measures of quality that we’re going to track really closely, and all of the normal functions of anti-trust regulations and others are watching for good behaviors.

I think the provider community will rise to that. In the ACO rule we’re offering a range of options about how you can get into this shared savings environment all the way from the track one of the rule in which you’re allowed to share savings but you don’t have any downside risk if costs go too high, way over to the pioneer program, offered now by the center for Medicare and Medicaid innovation which you can actually share more savings but take more risk if costs go too high. In all cases we’re protecting the beneficiary but watching care very, very closely to make sure that it’s improvements that’s generating the savings that we can now share.

There’s lots of interest in this all over the country. We’re going to see ACOs of many forms develop and I’m pretty excited about getting this rule into final form. I’ve got to thank, literally hundreds of your colleagues, people all over CMS, all over HHS indeed, and other government agencies have been getting together to help shape this rule to download and read the over 1200 comments we got to travel all over the United States getting feedback so that the final rule can be much better than the proposed rule as indeed it is.

I think we have a really exciting program on our hands. Many of you will be called upon to explain this rule to beneficiaries, to your friends and neighbors and your family. Now I’d like to make sure you have all the information you want about this. So log on to or find other ways to get information, inform yourselves and we’ll be reaching out with information to CMS employees so you can understand this wonderful, wonderful new program.

It’s part of the transition to the American health care system we want, which is really supporting care, to keep people healthy and which the whole structure of care shifts from volume to value from how much you do to how well the patient does and that’s what the ACO is intended to do. It’s a pretty exciting day. Thanks.

For the complete video and original transcript posted, click here.

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Proposed v. Final ACO Rule

By Gregg A. Masters, MPH

Deep in the 690+ pages of the document filed with the OFR, is a nifty little matrix that compares key provisions of the ‘notice of proposed rule making’ to the final rule which theoretically incorporated the best and brightest suggestions pro-offered in 1,300+ comments supplied to CMS.

That pre/post matrix can be accessed here. It is a good cheat sheet to follow along with some of the key provisions providing a fair amount of ‘stakeholder heartburn’.

In the end, and in the hard to please everyone department, AMA acknowledges CMS for reducing the number of quality measures, while ASCO expresses it concern over their reduction and failure to reflect the QM measures specific to oncology.

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ACOs: It’s Not Just About Medicare [shared savings]

By Gregg A. Masters, MPH

A recent report attached to a Tweet posted by Brian Ahier caught my attention in the blitzkreig of ACOs postings this past week.

 @ahier Building #ACO‘s & OUtcome Based Contracting in the Commercial Market

The complete title of the attached report is ‘Building ACOs and Outcome Based Contracting in the Commercial Market: Provider and Payor Perspectives‘.

This immediately caught my attention as for the better part of 30 years in the healthcare industry I spent a considerable amount of time in the managed care contracting business negotiating and signing my share of upstream (payor) as well as (downstream) hospital, physician and network agreements. From full risk, global capitated network deals to discounted fee for services to specialty care subcontracting and essential re-insurance backstops, I lived and breathed c/o/n/t/r/a/c/t/i/n/g.

Since the release of the proposed rule to implement the ACO provisions in the Affordable Care Act, most of the mainstream discussion has been about the ‘Medicare Shared Savings Program’, and considerably less attention has been paid to the activities delegated to the Center for Medicare and Medicaid Innovation (CMMI).

This report may change that singular focus since it broadens the loop and recognizes the market shift which is and has been rather active since the passage of the Act in March of 2010.

Call it ‘managed care 2.0, or 3.0’ or whatever you choose, the fix in healthcare, i.e., bending the cost curve. demonstrating the value proposition and improving access while reducing the rate medical inflation, if not lowering the cost of care, is rather well known: integration (legal, financial and operational) of medical practices under a banner of patient centered and coordinated (v. solo-ed or fragmented) care, enabled by information networks linked and seamlessly integrated across the continuum of care.

This was the same mission in the 70s and 80s when primarily HMO’s and to a lesser degree PPO’s were the mantra, yet the pain points did not exist as they do today, nor did the enabling technologies. The difference today is our house of cards sick care system is in the ICU on life support, and no one is defending the more is better, fee for services paradigm that drove our ‘healthcare borg’ to these heights of inefficiency and diminishing returns. Yet technology along with a determined shift in consciousness if not the sober recognition that ‘business as usual’ is not an option, gives us a materially different palette on which to collaborate towards a changed paradigm.

Check out this report and see what is already happening below the radar. You might be surprised. There is enough here to parse out over several posts and perhaps even invite the authors into a conversation on ‘ACO Watch: A Mid-Week Review’.

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ACO Final Rule: A Round Up of Early Opinion and ‘Go To’ Resources

By Gregg A. Masters, MPH

Like some of you, I woke up the morning of Friday, October 21st, 2011 to a literal ‘blitzkrieg’ of tweets flooding two TweetDeck columns tagged ‘ACOchat’ and ‘ACO’. Everyone it seems has a dog in the hunt to make known their standing or interest in Accountable Care Organizations (ACOs), the Medicare Shared Savings Program and related stuff, i.e., the Pioneer Program, Advanced Payment Model, etc.

Shortly after the final rule was published in the Federal Register, CMS conducted a ‘background’ stakeholder conference call. If you missed, you can listen via ACO Watch: A Mid-Week Review re-broadcast (note: we had some audio glitches, but got the entire call plus questions in).

Meanwhile for a list of some notable write ups and contributions, checkout:

As always first out of the box via @KHNewsHHS Releases Final Regulations for ACOs.

As well as the excellent contextual and opinion piece by Dr. Don Berwick in the New England Journal of Medicine, ‘Making Good on ACO’s Promise – The Final Rule for the Medicare Shared Savings Program‘.

My friend Michael L. Millenson and occasional guest poster on this blog chimes in with an insightful and witty Forbes piece titled: CMS Wants Docs to Ante Up to ACO Poker Game.

Meanwhile, the American Medical Association, one of several professional medical associations to back the Patient Protection and Afforable Care Act (bravo!), opines the net gain for docs via: Final ACO Rule Offers Promise to Improve Care Delivery, and CMS spotlights physician-friendly changes in final ACO rule.

The health plan and payor community checks in with AHIP’s, their trade association, posting: AHIP Statement on ACO Regulation.

While Esptein Becker’s Douglas A. Hastings posted on Health Affairs BlogValue-Based Payment, Accountable Care, and the ACO Final Rule: Are We Making Progress?

Also from the legal domain, McDermott Will Emery published: Medicare Shared Savings Program Final Rules  complete with comments and historical markup of key provisions in the PPACA the ACO final rule implements.

Of course the reference final rule summary from CMS is here, as well as the ‘fact sheets‘ previously posted to this blog, here.

From the ‘connect the dots’ health IT side of the conversation, i.e., hey you want an ACO…..gotta have the infrastructure, check out HealthData Management: ‘ACO Barriers‘ by Gary Baldwin.

And one of my favorites is from CMS in the Appendix titled: Proposed Rule versus Final Rule for Accountable Care Organizations (ACOs) In the Medicare Shared Savings Program.

There is more to come as we’re building the ‘go to’ resource portal for everything ACO.

p.s. Thursday, October 27th at 1PM Eastern there’s a FREE webinar that we’ll be following and tweeting from organized by @HCPlive and featuring fellow healthtweep David Harlow, aka @healthblawg, titled: Accountable Care Organizations, Bundled Payments, and the Future of Health Care. 

You can register here.

More later!

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HHS/CMS ‘Fact Sheets’ Per PR Issued Today on

EDITOR’S NOTE! Re: The press release ‘fact sheet’ for the ACO and Medicare Shared Savings Programs provisions as codified in today’s FINAL RULE, is published in it’s entirety below:

People with Medicare will be able to benefit from a new program designed to encourage primary care doctors, specialists, hospitals, and other care providers to coordinate their care under a final regulation on Accountable Care Organizations issued today by the Department of Health and Human Services (HHS). 

On October 20, 2011, HHS announced final rules and a new opportunity for financial support to help doctors, hospitals, and other health care providers work together to improve the care for Medicare patients.  By choosing to become Accountable Care Organizations, providers will be able to share in savings by better coordinating patient care, providing high quality care, and using health care dollars more wisely.

These new final rules, which were made final after an extensive review of comments and additional stakeholder input on the proposed rule, add a new option for providers looking for support in coordinating patient care. The Accountable Care Organization model of delivering care may not be right for every doctor, practice, clinic, or hospital, but it adds to the extensive menu of options offered through the Affordable Care Act to provide better health, better care and lower costs not only for Medicare beneficiaries, but for all Americans.

The new rules establish a new voluntary Medicare Shared Savings Program that helps doctors, hospitals, and other providers improve their ability to coordinate care across all health care settings. Providers who meet certain quality standards can share in any resulting savings.

The quality measures are organized into four domains:

  • Patient experience
  • Care coordination and patient safety
  • Preventive health
  • Caring for at-risk populations

The higher the quality of care providers deliver and the greater the effectiveness of their care coordination, the more savings they may keep.  Federal savings could be up to $940 million over four years.

In a complementary program announced today, HHS is accepting applications from providers to help test the Advance Payment model. This model will test whether pre-paying a portion of future shared savings will increase participation of physician-owned and rural Accountable Care Organizations in the Medicare Shared Savings Program, and whether advance payments will allow teams of providers to improve care for beneficiaries and generate Medicare savings more quickly.  The advance payments would be recovered from any future shared savings achieved by the team of providers.

These two new opportunities create incentives for health care providers to work together to treat an individual patient across care settings – including doctors’ offices, hospitals, and long-term care facilities.  Providers are not required to participate in Accountable Care Organizations, and patients of providers who participate continue to have control over which doctors they see and what care they receive.

Improving Care for Patients

Any patient who sees multiple doctors understands the frustration of fragmented and disconnected care: lost or unavailable medical charts, duplicated medical procedures, or having to provide the same information over and over to different health care providers.  This lack of coordination is even worse for patients with multiple chronic conditions who receive care from multiple health care providers.

Improved care coordination supported by these programs will lift this burden from patients, while improving the partnership between patients and doctors in making health care decisions.  People with Medicare will have better control over their health care, and their doctors can provide better care because they will communicate with the patient’s other care providers.

Patients choosing to receive care from providers participating in an Accountable Care Organization will have access to information about how well the organization is meeting the quality standards.

People with Medicare who receive care from a provider participating in an Accountable Care Organization will retain their rights to see any physician or hospital that participates in the Medicare program.  In other words, an Accountable Care Organization cannot restrict care or limit a Medicare beneficiary’s access to a physician or other health care professional. Medical decision making remains the responsibility of the patient and his or her doctor.

Helping Providers Coordinate Care

The two programs announced on October 20, 2011 are part of a broader effort by the Obama Administration to improve the quality of health care not only for Medicare beneficiaries, but for all Americans.  The Affordable Care Act supports several programs that help health care providers coordinate care.

  • Through the Partnership for Patients, more than 6,000 organizations including hospitals, doctors, and others have pledged to reduce hospital-acquired conditions and improve transitions in care.
  • The Bundled Payments initiative gives providers flexibility to work together to coordinate care for patients over the course of a single episode of an illness.
  • The Comprehensive Primary Care Initiative will allow Medicare to join with other health care payers such as employer-based health plans and/or Medicaid programs to invest in strengthening primary care.
  • The testing of the Pioneer Accountable Care Organization Model is designed for organizations with experience providing integrated care across settings.
  • The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration program is helping FQHCs provide more coordinated care and better access to primary care for Medicare patients.

Medicare Shared Savings Program

The new Medicare Shared Savings Program is intended to give Medicare fee-for-service beneficiaries the advantages of better coordination of care whether they get care in the hospital, a nursing facility, their doctor’s office, or their home.  The goal is to deliver seamless, high quality care for Medicare beneficiaries, and to make patients and providers true partners in care decisions.

Providers Eligible to Participate

Under the final rule, a group of providers and suppliers of services agree to work together with the goal that patients get the right care at the right time in the right setting.  The final rule requires that each group of providers be held accountable for at least 5,000 beneficiaries annually for a period of three years.  Each group must include health care providers and Medicare beneficiaries on its governing board.

All Medicare providers can participate in an Accountable Care Organization to coordinate care, but only certain types of providers are able to sponsor one.  Those providers include physicians in group practice arrangements, networks of individual practitioners, and hospitals that are partnering with or employ eligible physicians, nurse practitioners, physician assistants, and specialists.  To help providers serving rural and other underserved areas, the final rule allows Rural Health Clinics (RHCs) and Federally Qualified Health Centers to work together to coordinate care for patients.  In addition, in the final rule, certain critical access hospitals are also eligible.

Measuring Quality Improvement

The final rule links the amount of shared savings an Accountable Care Organization may receive, and in certain instances shared losses it may be accountable for, to its performance on: 1) quality standards on patient experience; 2) care coordination and patient safety; 3) preventive health; and 4) at-risk populations.  These standards will be measured in a way that accounts for providers who treat patients with more complex conditions.

To earn shared savings the first performance year, providers must fully and accurately report across all four domains of quality.  Providers will begin to share in savings based on how they perform in some of those 33 quality measures in the second and third performance years.

Sharing Savings and Sharing Losses

CMS is implementing two models: a one-sided shared savings model, in which providers only share in savings; and a two-sided shared savings and losses model, in which providers also share in losses if growth in costs go up.  The proposed rule had required Accountable Care Organizations in the one-sided shared savings model to share losses in the third year of the agreement period.  In response to comments, CMS has modified the proposal, and the final rule allows Accountable Care Organizations to participate under the one-sided shared savings-only model for the entire length of their first agreement period.  This will help organizations with less experience coordinating care, such as some physician organizations or small or rural providers, to gain experience before taking on the responsibility of sharing losses. It also allows more experienced providers to take on the responsibility of losses in exchange for greater potential rewards.  Accountable Care Organizations may share up to 50% of the savings under the one-sided model and up to 60% of the savings under the two-sided model, depending on their quality performance.

For each year, CMS will develop a target level of spending for each ACO to determine its financial performance. Because health care spending for any group of patients normally varies from year to year, CMS will also establish a minimum savings and minimum loss rate that would account for these variations.  This protects the Medicare Trust Funds from sharing savings, and providers against sharing in losses, due to normal variation in Medicare spending.  Both shared savings and shared losses will be calculated on the total savings or losses, not just the amount by which the savings or losses exceed the minimum savings or loss rate.  In addition, the amount of shared savings would depend on how well the team of providers performs on the quality measures specified in the rule.

To view a chart highlighting some of the key differences between the proposed and final rules visit: (PDF- 106 KB)

Advance Payment Model

The Advance Payment Model tests whether advancing a portion of an Accountable Care Organization’s future shared savings will increase participation from physician-owned and rural providers in the Medicare Shared Savings Program, and whether advance payments will allow those teams of providers more quickly improve care for beneficiaries and generate Medicare savings.  The Advance Payment Model was designed to support physician-owned and rural ACOs with upfront infrastructure investments.  These providers will receive payments in advance that will be recouped as they achieve savings.

There are three ways provider groups may receive these payments:

  • Upfront fixed payment
  • Upfront payment based on the number of Medicare patients served
  • Monthly payment based on the number of Medicare patients

This model is open only to physician-owned organizations, critical access hospitals, and rural providers participating in the Shared Savings Program, helping them become Accountable Care Organizations to improve care for their patients.  Application deadlines will match the Shared Savings Program.  For more details, visit

Antitrust Guidance for Providers

CMS has worked closely with the Department of Justice (DOJ) and the Federal Trade Commission (FTC) to facilitate the creation of Accountable Care Organizations by giving providers clear and practical guidance to form innovative, integrated health care delivery systems without raising antitrust issues.

Along with the final rule for the Shared Savings Program, DOJ and FTC have issued a joint Statement of Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program (“Antitrust Policy Statement”).  Under the Antitrust Policy Statement, the agencies will give rule of reason treatment to an Accountable Care Organization if they use the same governance and leadership structure and the same clinical and administrative processes in the commercial market as it uses to qualify for and participate in the Shared Savings Program.

In addition, the Antitrust Policy Statement outlines an expedited process that Accountable Care Organizations can use to obtain further guidance about their antitrust concerns.  For more details, visit and

For More Information

The Shared Savings Program final rule is posted at:

The Advanced Payment solicitation is posted at:

For more information on these two topics, fact sheets are posted at

The joint CMS and Department of Health and Human Services Office of Inspector General (OIG) Interim Final Rule with Comment Period addressing waivers of certain fraud and abuse laws in connection with the Shared Savings Program is posted at:

The Antitrust Policy Statement is posted at: and

The Internal Revenue Service (IRS) Fact Sheet, Tax-Exempt Organizations Participating in the Medicare Shared Savings Program Through Accountable Care (FS-2001-11), will be posted at: (PDF 52 KB).

Posted on: October 20, 2011