Local Docs Drive AMA Advocacy

Chicago physician shapes national conversation on ACO policy By Elizabeth Sidney

A CHICAGO MEDICAL SOCIETY resolution is driving discussion on Capitol Hill and other venues as the American Medical Association (AMA) pushes for ACO exclusivity policy refinements. The Society directive, authored by Rajeev Kumar, MD, argues that all physicians, both primary care providers and specialists, should have the freedom to participate in multiple ACOs. The measure directs the AMA to work with the Centers for Medicare and Medicaid Services to achieve alternatives to the current policy.

Under the CMS Services’ final rule, any practice that performs E&M services is precluded from full-fledged participation in more than one ACO regardless of specialty. All ACOs participating in the Medicare Shared Savings Program (MSSP) must provide primary care services to at least 5,000 patients, among other requirements.

Dr. Kumar’s resolution also takes issue with the federal agency’s decision to include nursing home visits within the definition of primary care. Physicians who practice in skilled nursing facilities or as medical directors of nursing homes should be allowed to participate in more than one ACO, the measure says.

A practicing geriatrician, Dr. Kumar first submitted his resolution to the Chicago Medical Society, where it was adopted and passed on to the Illinois State Medical Society (ISMS). After widening the original scope, the ISMS brought the directive to AMA for national advocacy.

With the next round of ACOs set to begin in 2015, the AMA has stepped up its communications with MedPAC. (This advisory body makes recommendations to the federal CMS agency.) As part of its campaign to influence MedPAC, the AMA is seeking examples from members on the detrimental effect of the exclusivity policy on physicians and their patients. MedPAC asked for more information on the impact of the current attribution methodologies, and notes that attribution should consider the different care patterns of different beneficiaries, as well as the range of providers engaged in primary care.

Leaders Discuss Chicago

The exclusivity policy is causing disruption in physician-patient relationships and practice patterns in the Chicago area, where ACO competition is strong. In fact, the Chicago region is cited as a major problem area in the AMA’s ongoing talks with CMS Services Administrator Marilyn Tavenner. The AMA’s proposed changes to the exclusivity policy outline several alternative paths for physician participation.

The MSSP created the ACO provider category to improve coordination and cooperation among physicians in the Medicare fee-for-service program. MSSPs reward ACOs that lower the growth of health care costs and its physicians who meet performance standards.

The MSSP regulation on ACOs was originally thought to allow non-primary care physicians to practice in multiple ACOs, but it later became clear that the CMS Services is applying exclusivity more broadly.

While the MSSP technically allows primary care physicians to participate in more than one ACO by filing under several tax identification numbers (TINs), this option requires setting up separate service and billing entities, potentially raising compliance issues.

A recent update clarifies that if a group practice bills Medicare for services under any billing codes that fall within the definition of primary care, the group TIN is not allowed to appear on the participant list for multiple ACOs. Since these services include all E&M codes, specialists are generally precluded from participation in multiple ACOs if they are billing E&M codes.

The CMS Services also noted that exclusivity applies only to the billing organization, as defined by the TIN, and not to individual providers. If individual physicians bill through more than one TIN, and if those TINs belong to different ACOs, the physicians themselves may also participate in different ACOs. Groups containing only specialists who do not provide primary care services are also allowed to participate in multiple ACOs.

PQRS Participation

ACO participants who are considered eligible providers will earn PQRS incentives as a group practice by reporting their clinical quality measures through the ACO Group Practice Reporting Option web interface.

ACO-affiliated primary care physicians serve as the main point of contact with participating Medicare beneficiaries. ACOs are required to perform and bill Medicare for specific E&M procedures to receive incentives under the MSSP.

Grassroots Participation Works

The steady stream of resolutions each year to the AMA demonstrates how individual physicians can influence discussion at the highest level of organized medicine.

Stay tuned when next month, the ISMS House of Delegates deliberates on multiple Society resolutions on topics as diverse as pharmacy formularies, burdensome electronic medical record technology, and maintenance of certification issues.