SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. The Next Wave of Healthcare Reform
  4. References
  5. Congress Takes Another Look at Immunosuppressant Coverage

Do accountable care organizations make sense for transplantation? This month, “The AJT Report” investigates how this element of healthcare reform may impact transplant patient care and clinical practice. Also this month, we look at new legislation that hopes to expand immunosuppressant drug coverage, and report on findings of a new study focused on risk factors for pediatric heart disease.


The Next Wave of Healthcare Reform

  1. Top of page
  2. Abstract
  3. The Next Wave of Healthcare Reform
  4. References
  5. Congress Takes Another Look at Immunosuppressant Coverage

inline image

Accountable care organizations (ACOs) are the latest government initiative to cut costs while providing better care. However, the role of transplantation in this new model is unclear—and, to some, not particularly attractive as currently designed. Indeed, transplantation has engaged in coordinated care models and may have useful insights for ACOs with regard to the care of patients with end-stage organ disease and other costly—but treatable—conditions.

What Is an ACO?

Section 3022 of the Patient Protection and Affordable Care Act requires the establishment of a Medicare Shared Savings Program by January 1, 2012. To accomplish this, the Centers for Medicare & Medicaid Services (CMS) have proposed ACOs, networks of care providers—likely to include primary care physicians, specialists and hospitals—in an integrated delivery system managing the care of at least 5,000 Medicare beneficiaries.1,2 Over a three-year contract period with CMS, providers would benefit financially by sharing in savings with the government if their costs come in lower than expected, or would need to repay the government if costs are too high. CMS estimates that ACOs will save Medicare $960 million over three years.

The Federal Trade Commission and Department of Justice have weighed in on ACOs, offering an antitrust Policy Statement because the very nature of ACOs “may raise concerns about competition.”3 The agencies say they will evaluate applicants that meet CMS eligibility criteria to ensure there is no violation of antitrust laws.

ACO participants have a choice of two payment models:

  • • 
    Share savings only for the first two years and both savings and losses in the third year;
  • • 
    Share savings and losses over all three years.

Each ACO will be required to track 65 different quality measures. And, although CMS estimates that the initial cost to form an ACO will be about $1.8 million, an analysis by the American Hospital Association puts start-up expenses at $11.6 million to $26.1 million.4 According to a commentary in the New England Journal of Medicine, these elements of the plan raise a fear that the savings from the formation of the ACOs would be too low in relation to the amount needed for start-up and, further, that the quality of standards set would be too high.5

Will Anyone Come to the ACO Party?

In an interview published on the Kaiser Health News website, George Halvorson, chairman and CEO of Kaiser Permanente hospitals and health plans, said the main ACO program “is probably going to have very few people signing up and is going to be almost a non-starter. But Medicare is creating some pilot programs with ACOs, and I think there are going to be a few dozen of these that are going to figure out ways of dealing with the patient population more directly.” He adds, “There's a third version of ACOs for the commercial healthcare insurance market; it's to help them work with sets of caregivers to figure out how to create team care. I think there's going to be a lot of energy in that area.”6

According to Michael Abecassis, MD, professor of surgery at Chicago's Northwestern University and immediate past president of the American Society of Transplant Surgeons (ASTS), ACOs make sense if you look at three assumptions:

  • 1
    Patients listen to their doctors;
  • 2
    You can save money if you cut down variation; and
  • 3
    You can come up with the right team to provide good quality care for less money.

However, he adds, “the only thing that keeps an ACO in business is how much money it saved compared with the benchmark of what was spent last year, then year to year.”

Dr. Abecassis then offered what he termed a “ridiculous example” that theoretically makes sense. “If I were running an ACO and had 3,000 elderly people, 500 of whom had dogs, I would hire dog walkers. In the winter, I would call the patients and offer a free service to walk their dogs, thus eliminating the chance of a fall on the ice and broken bones.” The whole idea behind ACOs, he says, is that “you have to become innovative enough to prevent bad things from happening to people. Doctors aren't used to assuming risk. They would have to create a whole infrastructure and start negotiating deals with providers. If you don't think you’re going to save money, why would you do it?”

KEY POINTS

  • • 
    Under the ACO model proposed by CMS, doctors and hospitals would be part of networks of care providers, and given financial incentives for keeping down costs while providing quality care for Medicare beneficiaries.
  • • 
    Transplant specialists worry that, in an effort to save costs under this model, PCPs may not refer patients, and beneficiaries will not have access to costly but medically necessary procedures, such as transplantation.
  • • 
    The ASTS is also concerned that quality measures in the ACO proposal don't include anything related to transplantation, and that specialists—who are often PCPs for patients with organ failure— aren't allowed to be PCPs under the current ACO design.

What Do ACOs Mean for Transplantation?

“When they set up ACOs, I’ll bet nobody even thought about highly specialized transplant care,” says Mitchell Henry, MD, professor of surgery at the Ohio State University Transplant Program in Columbus and current ASTS president. According to Dr. Henry, the greatest concern for transplant professionals is that primary care providers (PCPs), either from lack of knowledge or worries over cost, may not refer patients to them. Additionally, the ACO model focuses on savings within the three-year contract, and the health and cost advantages of transplantation are often much longer term.

In a June letter to CMS, the ASTS offered comments on the ACO plan. A few of their points are summarized below:

  • • 
    ASTS urges comprehensive education of patients regarding their options, especially if a transplant center is not included in the ACO network. ASTS recommends that ACOs state specifically that Medicare patients have access to relatively costly but medically necessary procedures, such as transplantation.
  • • 
    The 65 quality measures in the ACO proposal are problematic for transplantation because they don't include anything related to transplantation.
  • • 
    For patients with organ failure, the specialist is often the PCP However, specialists can't be PCPs under the current ACO design, and PCPs might limit referrals to specialists to achieve savings targets. The ASTS suggests that ACOs include a provision to monitor PCP referral patterns.
  • • 
    The ASTS requests that CMS eliminate indirect medical education (IME) and disproportionate share hospital (DSH) payments from the calculation of performance expenditures.
  • • 
    Noting that ACOs share a number of characteristics with transplant centers, the ASTS encourages CMS to consider transplant centers as models for ACOs.7

“Transplantation is a model when it comes to delivery and payment reform,” says Dr. Abecassis. “CMS and others just don't know it because nobody knows about transplant except transplant people. All the concepts about shared risk and bundled payments—the whole ACO thing—that's how we’ve been doing it for 20 years.”

References

  1. Top of page
  2. Abstract
  3. The Next Wave of Healthcare Reform
  4. References
  5. Congress Takes Another Look at Immunosuppressant Coverage

Congress Takes Another Look at Immunosuppressant Coverage

  1. Top of page
  2. Abstract
  3. The Next Wave of Healthcare Reform
  4. References
  5. Congress Takes Another Look at Immunosuppressant Coverage

Bipartisan legislation to expand immunosuppressant drug coverage was introduced in the U.S. Senate this summer and is expected to be introduced in the House this fall in another attempt to get lifetime Medicare coverage for the drugs needed by transplant patients.

The same bill was introduced last year and passed in the House, but was then discarded in the Senate after heavy lobbying by dialysis groups opposed to the bill's inclusion in end-stage renal disease (ESRD) bundling of payments. The transplantation community was frustrated when the bill was also opposed by the National Kidney Foundation (NKF), whose president, Bryan Becker, MD, says Congressional staff found that a change in dialysis reimbursement was needed to pay for more anti-rejection medication, and the NKF would not condone “robbing Peter to pay Paul.”

The entire [transplant] community has bonded together to get patient immune coverage to the finish line.

William Applegate

It's going to be different this year, according to William Applegate, senior vice president and policy analyst for St. Louis's Bryan Cave, the American Society of Transplantation's (AST) advocate on the Hill. As opposed to last year's complications regarding the pay-for/offset for immune coverage, Applegate and AST are encouraged “that the entire community has bonded together to get patient immune coverage to the finish line in the 112th Session of Congress,” he says.

Applegate has been joined in lobbying efforts on the Hill by representatives from AST and the NKF. “We believe the best chance for passage this time is to get balanced support from Democrats and Republicans, especially the top people in both parties,” he says. To help in this effort, a letter went out on August 2 to all 535 members of Congress, explaining the bill and urging co-sponsorship. The letter was signed by the AST, the ASTS, the NKF, and 16 other renal, transplant and diabetes organizations.