Brief: ACO rule could exclude FQHC patients
The Centers for Medicare and Medicaid Services (CMS) interpretation of the regulations in the Patient Protection & Affordable Care Act (PPACA) could exclude federally qualified health center (FQHC) patients from the Medicare Shared Savings Program (MSSP), according to a research brief from Geiger Gibson/RCHN Community Health Foundation Research Collaborative.
“CMS policy has the potential to produce a series of downstream consequences, most notably, the systemic exclusion of the poorest and most underserved patients from the benefits of accountable care organizations (ACOs) and the disincentivization of meaningful federally qualified health center (FQHC) affiliation agreements with hospitals and specialty groups participating in ACOs,” wrote Sara Rosenbaum, JD, and Peter Shin, PhD, MPH, both from the George Washington University School of Public Health and Health Services’ department of health policy, in Washington, D.C.
On March 31, 2011, CMS released proposed regulations implementing the Medicare Shared Savings Program (MSSP). “The thrust of the MSSP is to promote savings to Medicare as well as the greater clinical integration of healthcare through incentive payments to ACOs that meet Medicare standards for structure, performance and healthcare outcomes. The effort to spur greater clinical integration through the MSSP was part of a broader set of reforms contained in the PPACA," wrote Rosenbaum and Shin.
Among these reforms is an $11 billion investment in FQHCs under the Medicare program, they noted. In 2009, FQHCs served nearly 19 million low-income patients, including 1.4 million Medicare beneficiaries. “By law, health centers must provide comprehensive primary healthcare while also serving as gateways to a full range of necessary care, including inpatient and specialty care.” Federal data show that primary care represents 98.2 percent of all healthcare furnished by FQHCs, according to the authors.
Rosenbaum and Shin asserted that CMS’ proposed rule bars participation by FQHC-formed ACOs, and while the rule permits FQHCs to be ACO participants, it also prohibits the assignment of Medicare patients to ACOs for shared savings purposes. “Despite the absence of any legal barriers to FQHC participation in the statute, CMS bases this exclusionary policy on the fact that the FQHC payment method, which consists of a bundled payment for all primary healthcare services furnished by FQHC staff, does not allow the agency to identify which procedures are furnished by physicians, whose presence in care provision is a requirement of the ACO statute,” they wrote.
In medically underserved communities, however, healthcare teams are essential because of the severe shortage of physicians; furthermore, FQHCs use healthcare teams to ensure comprehensive care, argued the authors.
The ACO statute gives the secretary of Health and Human Services the discretion to interpret the statute’s assignment rule to recognize physicians as providers of healthcare regardless of whether they furnish healthcare directly or as part of healthcare teams, the report concludes. “Although technical issues will arise in designing a shared savings methodology for healthcare team arrangements that rely on bundled payments, this challenge ultimately pales alongside the implications of excluding FQHC Medicare patients from the potential benefits of ACO practice.”
“CMS policy has the potential to produce a series of downstream consequences, most notably, the systemic exclusion of the poorest and most underserved patients from the benefits of accountable care organizations (ACOs) and the disincentivization of meaningful federally qualified health center (FQHC) affiliation agreements with hospitals and specialty groups participating in ACOs,” wrote Sara Rosenbaum, JD, and Peter Shin, PhD, MPH, both from the George Washington University School of Public Health and Health Services’ department of health policy, in Washington, D.C.
On March 31, 2011, CMS released proposed regulations implementing the Medicare Shared Savings Program (MSSP). “The thrust of the MSSP is to promote savings to Medicare as well as the greater clinical integration of healthcare through incentive payments to ACOs that meet Medicare standards for structure, performance and healthcare outcomes. The effort to spur greater clinical integration through the MSSP was part of a broader set of reforms contained in the PPACA," wrote Rosenbaum and Shin.
Among these reforms is an $11 billion investment in FQHCs under the Medicare program, they noted. In 2009, FQHCs served nearly 19 million low-income patients, including 1.4 million Medicare beneficiaries. “By law, health centers must provide comprehensive primary healthcare while also serving as gateways to a full range of necessary care, including inpatient and specialty care.” Federal data show that primary care represents 98.2 percent of all healthcare furnished by FQHCs, according to the authors.
Rosenbaum and Shin asserted that CMS’ proposed rule bars participation by FQHC-formed ACOs, and while the rule permits FQHCs to be ACO participants, it also prohibits the assignment of Medicare patients to ACOs for shared savings purposes. “Despite the absence of any legal barriers to FQHC participation in the statute, CMS bases this exclusionary policy on the fact that the FQHC payment method, which consists of a bundled payment for all primary healthcare services furnished by FQHC staff, does not allow the agency to identify which procedures are furnished by physicians, whose presence in care provision is a requirement of the ACO statute,” they wrote.
In medically underserved communities, however, healthcare teams are essential because of the severe shortage of physicians; furthermore, FQHCs use healthcare teams to ensure comprehensive care, argued the authors.
The ACO statute gives the secretary of Health and Human Services the discretion to interpret the statute’s assignment rule to recognize physicians as providers of healthcare regardless of whether they furnish healthcare directly or as part of healthcare teams, the report concludes. “Although technical issues will arise in designing a shared savings methodology for healthcare team arrangements that rely on bundled payments, this challenge ultimately pales alongside the implications of excluding FQHC Medicare patients from the potential benefits of ACO practice.”