A CMS request for information does a good job of outlining the alternatives "Some argue it is necessary to attribute beneficiaries before the start of a performance period, so the ACO can target care coordination strategies to those beneficiaries whose cost and quality information will be used to assess the ACO's performance; others argue the attribution should occur at the end of the performance period to ensure the ACO is held accountable for care provided to beneficiaries who are aligned to it based upon services they receive from the ACO during the performance period. How should we balance these two points of view in developing the patient attribution models for the Medicare Shared Savings Program and ACO models tested by CMMI?"
The Disease Management Care Blog agrees with Drs. Feder and Cutler 's answer. In the long term, the success of ACOs' will be the direct result of how well they reconcile the twin issues of protecting the rights as well as enabling the responsibilities of health consumers. If the ACO business model is ultimately based on "shared savings," it'll ultimately be the patientconsumers who determine whether "bending the curve" was the result of good doctoring or unjust denials. Sooner or later, it'll be the patients - the ones who vote, write to members of Congress, call their State Attorney Generals and get interviewed by news organizations - who will need to buy-in to the merits of "high value" health care services.
How can consumers be assured that they're not being screwed by their ACOs? In addition to being assigning ahead of time, patients should be given the disease management-invented option of being presented with a care plan "contract" that represents an "opt-in" or, better yet, being automatically signed up and then being given the ability to "opt out." In addition, consumers will be more likely to support their ACOs if they know there reasonable rules for consumer protection. Examples of this include having 1) ready access to an ombudsman and 2) provisions for getting second opinons and external appeals if there is disagreement about getting costly health care.
Last but not least, Feder and Cutler also suggest there should be a mechanism that allows the participating consumers to also financially benefit if there are any savings. The naive "why not?" DMCB wholeheartedly agrees. That kind of arrangement has a distant relationship with old fashioned and consumer-friendly "mutual" style insurance arrangements, is in the same spirit of the novel MLR ceiling rebates and would be a refreshing example of how health care savings don't have to go to funding Medicare's spiraling deficits, an insurer's surplus or a hospital's capital campaign. The DMCB thinks this is something that Democrats, Republicans, Progressives and Republicans could agree with.