You see, the government realized preemptively that ACOs were a possible avenue for antitrust issues. CMS recognized that healthcare providers would be more likely to integrate their care delivery for Medicare beneficiaries through ACOs if they could also use the same ACO for commercial insurance. This would likely lead to a new delivery and payment system with commercial payers, which might also inspire some unsavory results, such as price fixing and market allocation agreements among competing healthcare providers. All of which would drive up the cost of consumer care.
“The agencies recognize that not all such ACOs are likely to benefit consumers, and under certain conditions ACOs could reduce competition and harm consumers through higher prices and lower quality of care. Thus, the antitrust analysis of ACO applicants to the Shared Savings Program must ensure that ACOs have an opportunity to achieve substantial efficiency yet the analysis must remain sufficiently rigorous to protect both Medicare beneficiaries and commercially insured patients from potential anticompetitive harm,” CMS wrote in the document.
If you are considering partnering with one of your competitors to set up an ACO, the proposed regulations may make it challenging depending on the size and location of your organization. Then again, not attempting to establish an ACO in your area could prove to be a market share blunder, if the authors of the NEJM are correct.
Which brings me back to my original question: Are the potential cost savings worth the effort to establish an ACO, and if so, is now the time to act? The true answer is that every healthcare organization must carefully decide for itself. The best guidance anyone can offer is to be sure to complete your due diligence before deciding to pursue or disregard this initiative.