Wolterman calls the proposed retrospective assignment of ACO beneficiaries "a difficult sell" that could discourage many providers from taking up the new model. "First and foremost they have to assign the Medicare beneficiaries ahead of time. You have to know who your patients are to be able to work with them to modify their lifestyle and manage their chronic diseases, and navigate that patient through the complex healthcare system," he said.
Wolterman says he was told that the federal government doesn't want to identify ACO beneficiaries ahead of time, because they don't want providers to skimp on care to keep costs down, a justification that he says doesn't hold water. "The whole concept that they aren't going to assign them to us because we are going to skimp on care -- that just says you don't trust the system," he says. "I don't believe that skimping will happen. You have these people for three years. If you skimp in the first or second year on a hypertensive patient they may come back with a stroke or a (myocardial infarction)and cost a lot more the third year."
Benjamin Isgur, director of PwC's Health Research Institute, told HealthLeaders Media that Wolterman and other healthcare executives are raising legitimate concerns. "That's why we're saying don't underestimate the infrastructure that is going to be required for a successful ACO model," he says. "If you look at the rules, if you aren't already a fairly integrated organization, there are some pretty daunting things there. You have to have EMR working well so you can analyze the data. You are going to have to meet more quality requirements than any other CMS program. You have to manage a population that might be difficult to manage because you might not know exactly who is in your ACO until after the first full year. There are a lot of infrastructure and sophistication issues that organizations should not underestimate."