By Jane Norman, CQ HealthBeat Associate Editor
April 1, 2011 -- The Obama administration is selling a plan to coordinate Medicare services, and the program’s success now rests on whether skeptical seniors will choose to participate.
Experts say education will be pivotal to keep beneficiaries from taking any complaints to Congress, where lawmakers have proved highly sensitive to the protests of the powerful elder lobby.
Officials with the Centers for Medicare and Medicaid Services (CMS) announced Thursday proposed rules for accountable care organizations, known as ACOs, that the health care law (PL 111-148, PL 111-152) created. The organizations are intended to get groups of doctors, hospitals and health systems to better coordinate care for Medicare patients. The organizations will create incentives to reward providers if they lower health care costs and meet quality-of-care standards.
The organizations, by design, will do away with unnecessary tests and avoid the need for multiple medical histories for each doctor or specialist.
Federal officials expect 75 to 150 of the organizations to form over the next three years, with about 1.5 million to 4 million of the nation’s 46 million Medicare patients to participate. Savings are projected to reach $960 million in the first three years.
The organizations are entirely voluntary—for patients and for providers. Medicare officials insist that the organizations will not limit health care services by using such managed care techniques as directing seniors to use only member providers.
"An ACO will not limit patient choice," said CMS Administrator Donald M. Berwick. But polls show that seniors already are more skeptical of the health law than most Americans, in part because they’re worried about the impact of Medicare payment cuts on access to care. Seniors also hear growing talk in Congress about curbing entitlements. All of this may influence their willingness to take part in a program that’s new and aims to contain costs.
"My guess is some of these things will start to merge in seniors' minds and they will feel they are under attack," said Maria Freese, vice president for government relations at the National Committee to Preserve Social Security and Medicare.
Certainly, there is a history of seniors rebelling against changes in Medicare. A law enacting catastrophic care was repealed in 1989 after seniors protested a tax that it levied. And the 2006 prescription drug benefit under Medicare, while it survived, faced initial rough going amid confusion about choices offered and frustration with its complexity.
Lawmakers will be monitoring developments. Sen. Orrin G. Hatch of Utah, the top Finance Committee Republican, said the administration has to give lawmakers time to study a proposal that will fundamentally restructure the Medicare system. “Any attempt to short circuit this process would be detrimental to our nation’s doctors and seniors” who need to know the impact, said Hatch.
But Finance Committee Chairman Max Baucus, D-Mont., predicted "top-notch patient care" as well as cost savings.
For it to work, seniors will have to have confidence they will continue to have a choice of providers, said Robert Blendon, professor of health policy and political analysis at the Harvard School of Public Health. "If this gets to be restrictive for seniors, there will be a substantial backlash," he said. "If it looks like it's improving service and coordination, it’s something that would be seen as very positive. People would go out of the system less. But they still would know they have the option."
The law does not require seniors be informed they might be assigned to an ACO. But the proposed rule notes success will be undermined if seniors lack sufficient information. So the regulations call for the development of a communications plan, including educational materials and outreach.
Seniors will be told they may be assigned to an ACO, and that if they agree, their health information may be shared among group providers. During office visits, patients would get forms detailing how they could opt out of the ACO. And the Medicare handbook will be updated.
One problem, though, is that Medicare recipients will not know until the end of the year whether their current doctor has become affiliated with an ACO. AARP, the senior lobbying group, already has expressed misgivings about this issue. The proposed solution is to post notices in provider offices and distribute handouts to patients informing them when providers join or drop out of the groups.
Stuart Guterman, a vice president at the Commonwealth Fund, said the participation of seniors will be critical to the program’s success. The emphasis must be on what seniors will gain, he said.
"When you leave one building, a doctor’s office or a hospital, the next thing that happens to you is planned and is aimed at making you better," he said. “That’s a message that has to be gotten across.”
Blendon said seniors will complain loudly to Congress if ACOs prove restrictive despite the promises of providing choice. If beneficiaries can’t see providers they’ve seen before, "I think members of Congress and the administration are going to hear from seniors," he said.