With all the recent discussion on the Affordable Care Act (ACA) being heard before the Supreme Court, I wanted to discuss one of the programs that was borne from the ACA. The Centers for Medicare & Medicaid (CMS) define Accountable Care Organizations (ACOs) as "... groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors."
Wow, this sounds great so far, and seems to be congruent with nurse practitioner-partnered care, what could be wrong with this model? Read on.
The "ACO Professional" is defined, "...as a physician (as defined in section 1861(r)(1) of the Act) or a practitioner described in section 1842(b)(18)(C)(i) the Act (that is, a physician assistant, nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act))."
Wow, a win-win all around - a new model of care that is coordinated to reduce waste and duplication, utilizes nurse practitioners and is part of federal legislation. What's the catch?
It is embedded here in the Federal Register:
Thus, although the statute defines the term ‘‘ACO professional’’ to include both physicians and non-physician practitioners, such as advance practice nurses, physician assistants, and nurse practitioners, for purposes of beneficiary assignment to an ACO, the statute requires that we consider only beneficiaries’ utilization of primary care services provided by ACO professionals who are physicians. The method of assigning beneficiaries therefore must take into account the beneficiaries’ utilization of primary care services rendered by physicians. Therefore, for purposes of the Shared Savings Program, the inclusion of practitioners described in section 1842(b)(18)(C)(i) of the Act, such as PAs and NPs in the statutory definition of the term ‘‘ACO professional’’ is a factor in determining the entities that are eligible for participation in the program (for example, ‘‘ACO professionals in group practice arrangements’’ in section 1899(b)(1)(A) of the Act). However, assignment of beneficiaries to ACOs is to be determined only on the basis of primary care services provided by ACO professionals who are physicians.
Did you catch that? Yes, that's right, while NPs are included as "ACO Professionals," if a Medicare patient utilizes a nurse practitioner as their provider, they are not eligible to participate in the ACO unless the beneficiary is assigned to a physician. If that seems non-sensical to you, that's because it is.
So what can NP practices do who want to participate in this money saving model of care (where half of the savings are reaped by the practice)? Unfortunately, the public comment period has closed on this issue. Right now, if an NP-owned practice wanted to participate in a similar type of shared savings model, they would have had to apply for a grant under the CMS Innovation Program and hope to get a similar award for what an ACO would bring. That deadline was due in January and the actual awards should be announced any day.
This is where NPs get shut out of the system. Yes, NPs may participate in an ACO, will improve care, reduce costs and duplication, but the only party benefitting is the physician or hospital-owned ACO. We must let our representatives know how backwards this is. The national nurse practitioner organizations have weighed in on this issue via the NP Roundtable but nothing has really changed. Doesn't seem fair, does it?