Well, as the old adage says, the devil is in the details and it is very likely that before Halloween we'll know if the federal government's shared savings program is a trick or a treat. The Office of Management and Budget made it known last week that it was reviewing the final rule to establish accountable care organizations.


Staff at the Centers for Medicare & Medicaid Services certainly had their work cut out for themselves. The agency's draft regulation, which is largely considered the centerpiece to the Affordable Care Act's promise to redesign the health care system, landed in the spring with a considerable thud. Providers, payers, policy wonks — really, anyone interested in health care — had eagerly awaited the proposal, hoping to see some creative thinking on reimagining care delivery. Instead, the proposal was universally lambasted.

The American Hospital Association, in its comments on the rule, noted that "since the release of the proposed regulation, excitement about Medicare ACOs has dwindled dramatically. Many of our members are disappointed with the design of the ACO program as proposed. Substantial changes are needed to make the program operationally viable and attractive to potential participants."

America's Health Insurance Plans said that CMS, in both the shared savings program and the later-announced Pioneer ACO pilot, "misses an opportunity … to fully capitalize on the progress being made in the private sector by developing program requirements that do not align with existing efforts and could create marketplace disruption."

We know that hospital executives are intrigued by the concept of accountable care. Many have launched or are looking into launching an accountable care model in their communities. In June, my colleague Haydn Bush talked with Lee Sacks, M.D., chief medical officer at Chicago-based Advocate Health Care about its ACO with Blue Cross Blue Shield. We also know that some of the nation's leading systems, including Advocate, Mountain States Health Alliance and Scripps Health are applying to be part of CMS' Pioneer pilot. Despite the fact that the shared savings final regs haven't been issued, executives at these hospitals think that the Pioneer pilot will likely be more flexible and offer greater opportunity to innovate.

With so much focus on the care continuum and improving clinical integration, not to mention bringing costs under control, there's a lot at stake with the shared savings program. I spent 15 years in D.C. earlier in my career covering a number of regulatory agencies. Substantial changes are often made from the proposed to final rule. Submitted comments are taken seriously. We'll just have to wait and see what CMS came up with in its second pass at the ACO concept. Once the final rule is out, we'd like to know what you think of it. Email me at mweinstock@healthforum.com.