New ACO proposals could leave long-term care providers smiling

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James Berklan
James Berklan

If nothing else, federal health officials displayed Monday that they are intent on getting this accountable care organization thing right. Or at least closer to “right” than it has been.

The Centers for Medicare & Medicaid Services released draft rules that were a tacit acknowledgement that something needed to be done to plug a leaky bucket. Officials were expected to release new rules back in August but they quietly bided their time, producing a lot of provider anxiety along the way.

This, in part, was fueled by regulators' own anxieties. Monday's draft rule release clearly reflects a “We heard you” sentiment after the defection this fall of several more ACOs from the Pioneer program, the same model that was designed to entice and reward top performers.

Long-term care policy experts were still sifting through the proposal Tuesday, but all fingers are crossed that they will turn out as positive as they first seem to be.

For one, CMS has asked for comments on how waivers of the three-day inpatient rule should be granted. This is a very good sign because officials seem to be indicating that much more widespread use of waivers is a given. They just don't want to grant blanket approval outright.

Expect LTC lobbyists to be extremely busy crafting comments. The timing of this draft release gives them more than a month of the new year to finalize thoughts.

It's not clear where large scale opposition to waiving the three-day rule would come from since the usual thorns in the side — hospitals and physicians — should be on board with it. Anything that would lower ACO care costs, such as lower-cost SNF placement, should make all team members happy.

Under the proposed rules, hospitals also would still get to control which patients get to go to SNFs. This continued gatekeeper role should keep them happy.

Monday's release also showed how much CMS is trying to make the ACO program similar to Medicare Advantage offerings. Regional, not national, spending data would be used to develop target benchmarks for pricing, for example.

This could lead to more flourishing ACOs where Medicare Advantage flourishes (and fewer ACOs where Medicare Advantage is not prevalent). But it's a start toward wider adoption.

Regulators also have proposed a third risk track, which ostensibly was created to keep providers from dropping out of ACO efforts altogether. Clearly, they'd like providers to assume more downstream risk — and they're offering greater rewards for those who would do so — but they also are saying that one doesn't have to be particularly daring to remain a part of the ACO family. In what appears to be a major victory for providers, ACOs would no longer be forced into assuming more risk after three years in the program.

If there's anything unsettling for LTC providers about the new proposal, it's that more guidelines on how to develop networks were not included. We should expect to see lobbyists push for more targeted guidance on how would-be partners from the acute-care world should evaluate long-term care and other post-acute providers.

As it is now, the networks can place emphasis on differing sets of standards, leaving post-acutes unsure as to whether they're focusing on the right things to be allowed into the ACO club. And that ain't right.

James M. Berklan is McKnight's Editor. Follow him @LTCEditorsDesk.

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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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