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Accountable Care News: May 2015, Thought Leaders’ Corner

Accountable Care News approached David Fairchild, MD, MPH, Director with BDC Advisors, to discuss “Section 512 of the legislation repealing the SGR calls on the Secretary of HHS in consultation with the Inspector General to review and make recommendations to Congress in 12 months on options to amend the gainsharing rules. Could this be a big deal for ACOs? How might it affect CMS revenue paid to ACOs? How would you amend the rules?”

Dr. Fairchild commented: “Section 512 brings the Gainsharing CMP (Civil Monetary Penalties) into closer step with the provisions of the ACA that allows providers to enter into certain shared-savings arrangements with ACO’s and their clinically integrated networks of physicians.

Because of the new protections available under the ACA, the Office of Inspector General had already determined in October that pending further notice, gainsharing arrangements were no longer going to be an enforcement priority — unless there was evidence that beneficiaries were being deprived of ‘medically necessary services’ — a distant possibility given the quality safeguards built into all shared savings contracts. Of course, we will need to see how CMS will interpret the phrase ‘medically necessary’. But for now at least it appears that gainsharing rules are off the table as a big ACO concern since the OIG has clearly signaled it is giving enforcement a low priority.

In terms of suggesting future gainsharing rules, we think the main focus should be improving the viability of the ACOs business model. We agree with the NAACO that the current balance between risk and rewards for the current ACOs is not a sustainable long term business model. The new gainsharing recommendations should address the need for streamlined quality metrics that reflect a ‘better, smarter, simpler’ way of managing care.”


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