[Federal Register Volume 75, Number 221 (Wednesday, November 17, 2010)]
[Proposed Rules]
[Pages 70165-70166]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-28996]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Chapter IV
[CMS-1345-NC]
Medicare Program; Request for Information Regarding Accountable
Care Organizations and the Medicare Shared Saving Program
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Request for information.
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SUMMARY: This document is a request for comments regarding certain
aspects of the policies and standards that will apply to accountable
care organizations (ACOs) participating in the Medicare program under
section 3021 or 3022 of the Affordable Care Act.
DATES: Comment Date: To be assured consideration, comments must be
received at one of the addresses provided below, no later than 5 p.m.
on December 3, 2010.
ADDRESSES: In commenting, please refer to file code CMS-1345-NC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow ``Submit a comment''
instructions.
By regular mail. You may mail written comments to the
following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1345-NC, P.O.
Box 8013, Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
By express or overnight mail. You may send written
comments to the following address ONLY: Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Attention: CMS-1345-
NC, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-
1850.
By hand or courier. Alternatively, you may deliver (by
hand or courier) your written comments ONLY to one of the following
addresses prior to the close of the comment period:
a. For delivery in Washington, DC-- Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD-- Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
call telephone number (410) 786-7195 in advance to schedule your
arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as
appropriate for hand or courier delivery may be delayed and received
after the comment period.
FOR FURTHER INFORMATION CONTACT: Thomas Carey, (410) 786-4560 or
[email protected].
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
I. Background
The Affordable Care Act seeks to improve the quality of health care
services and to lower health care costs by encouraging providers to
create integrated health care delivery systems. These integrated
systems will test new reimbursement methods intended to
[[Page 70166]]
create incentives for health care providers to enhance health care
quality and lower costs. One important delivery system reform is the
Medicare Shared Savings Program under section 3022 of the Affordable
Care Act, which promotes the formation and operation of accountable
care organizations (ACOs). Under this provision, ``groups of providers
* * * meeting the criteria specified by the Secretary may work together
to manage and coordinate care for Medicare * * * beneficiaries through
an [ACO].'' An ACO may receive payments for shared savings if the ACO
meets certain quality performance standards and cost savings
requirements established by the Secretary. We are developing rulemaking
for the establishment of the Shared Savings Program under section 3022
of the Affordable Care Act. In addition, section 3021 of the Affordable
Care Act establishes a Center for Medicare and Medicaid Innovation
(CMMI) within CMS, which is authorized to test innovative payment and
service delivery models to reduce program expenditures while preserving
or enhancing the quality of care. We are considering testing innovative
payment and delivery system models that complement the Shared Savings
Program in the CMMI. In both of these efforts, we are seeking to
advance ACO structures that are organized in ways that are patient-
centered and foster participation of physicians and other clinicians
who are in solo or small practices.
We have already conducted substantial outreach and had discussions
with and received feedback from a wide array of physician groups, as
well as groups representing other clinicians, hospitals, employers,
consumers, and other interested parties, about how ACO programs can
best be structured. In particular, CMS, along with the Office of the
Inspector General (OIG) of the Department of Health and Human Services
(DHHS) and the Federal Trade Commission hosted a public workshop on
October 5, 2010, to discuss the application and enforcement of the
antitrust laws, physician self-referral prohibition, Federal anti-
kickback statute, and civil monetary penalty law to the variety of
possible ACO structures under the Shared Savings Program and other
innovative payment models that CMMI is authorized to test under section
3021 of the Affordable Care Act. Prior to the public workshop, the
three agencies solicited written comments and statements from industry
stakeholders regarding a variety of issues, including the planned legal
structures and business models of ACOs.
II. Solicitation of Comments
As we develop our initial rulemaking for the Shared Savings Program
and begin the development of potential models in the CMMI, we are
seeking additional information, particularly from the physician
community, on the following questions:
What policies or standards should we consider adopting to
ensure that groups of solo and small practice providers have the
opportunity to actively participate in the Medicare Shared Savings
Program and the ACO models tested by CMMI?
Many small practices may have limited access to capital or
other resources to fund efforts from which ``shared savings'' could be
generated. What payment models, financing mechanisms or other systems
might we consider, either for the Shared Savings Program or as models
under CMMI to address this issue? In addition to payment models, what
other mechanisms could be created to provide access to capital?
The process of attributing beneficiaries to an ACO is
important to ensure that expenditures, as well as any savings achieved
by the ACO, are appropriately calculated and that quality performance
is accurately measured. Having a seamless attribution process will also
help ACOs focus their efforts to deliver better care and promote better
health. Some argue it is necessary to attribute beneficiaries before
the start of a performance period, so the ACO can target care
coordination strategies to those beneficiaries whose cost and quality
information will be used to assess the ACO's performance; others argue
the attribution should occur at the end of the performance period to
ensure the ACO is held accountable for care provided to beneficiaries
who are aligned to it based upon services they receive from the ACO
during the performance period. How should we balance these two points
of view in developing the patient attribution models for the Medicare
Shared Savings Program and ACO models tested by CMMI?
How should we assess beneficiary and caregiver experience
of care as part of our assessment of ACO performance?
The Affordable Care Act requires us to develop patient-
centeredness criteria for assessment of ACOs participating in the
Medicare Shared Savings Program. What aspects of patient-centeredness
are particularly important for us to consider and how should we
evaluate them?
In order for an ACO to share in savings under the Medicare
Shared Savings Program, it must meet a quality performance standard
determined by the Secretary. What quality measures should the Secretary
use to determine performance in the Shared Savings Program?
What additional payment models should CMS consider in
addition to the model laid out in Section 1899(d), either under the
authority provided in 1899(i) or the authority under the CMMI? What are
the relative advantages and disadvantages of any such alternative
payment models?
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: November 10, 2010.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2010-28996 Filed 11-12-10; 4:15 pm]
BILLING CODE 4120-01-P