Mary Ellen Schneider

Dr. Douglas Carlson initially trained as a pediatric emergency physician and didn’t really start to think of himself as a pediatric hospitalist until a decade ago.

But today he heads up the division of pediatric hospital medicine at Washington University in St. Louis and devotes many of his off hours to ensuring that more pediatricians will choose hospital medicine as a life-long career.

“We’ve put a lot of thought into making sure these are true careers,” he said.

One of the biggest changes in the last few years has been a move away from physicians’ choosing to spend just a few years as pediatric hospitalists and moving on. Instead, those physicians who choose the specialty are staying in it longer, noted Dr. Carlson, who co-chairs a workforce committee for the Pediatric Hospital Medicine Strategic Planning Roundtable and served on the Society of Hospital Medicine’s Career Satisfaction Task Force.

Drawing physicians to pediatric hospital medicine, however, remains a challenge. Factors such as scheduling, workload, autonomy, and compensation are all important in attracting physicians to the speciality and preventing burnout. However, recognition tends to trump those issues in the eyes of most young pediatricians who are thinking about their career choices, he said.

Academic medical centers and community hospitals have been showing signs of a greater awareness of the skills that pediatric hospitalists possess that other specialists don’t bring to the table, he said. In increasing numbers, pediatric hospitalists are moving into leadership roles in their hospitals, becoming chief medical officers, for instance. And at Washington University, where Dr. Carlson works, hospital medicine became an official division within the pediatric department last September. That type of recognition is vital, he said, because many young hospitalists fear not being seen as equal to their peers in other specialties such as cardiology or gastroenterology. “But I think that’s changing rapidly,” he said.

The next step is for pediatric hospitalists to gain recognition from the American Board of Pediatrics (ABP). Dr. Carlson and others in the field are working to bring together a diverse group of pediatric hospitalists to help design the ideal pathway for certification in pediatric hospital medicine.

The American Board of Internal Medicine and the American Board of Family Medicine both recently established a “recognition of focused practice” pathway in hospital medicine for their currently certified diplomates. But so far, the ABP has been more reluctant to follow with a similar model for pediatrics, he said.

Along with persuading the leadership of the ABP to embrace the idea of certification, another major challenge is to design a pathway that continues to allow for growth in the field. Dr. Carlson said he sees value in offering 1- or 2-year fellowships in pediatric hospital medicine, which would help build the scholarly foundation of the specialty. However, he worries that it would be difficult to convince young physicians to spend those extra years in training. And it would be a challenge just to keep up with the demand. Dr. Carlson estimates that there would need to be 100-200 fellowship positions per year to keep up with the current growth in the field. “That’s a huge amount,” he said.

But he says that he is confident that these issues can be worked out in the next few years.

The double-digit growth in the field will likely slow slightly and jobs may not be quite as easy to find, he predicted. Talented physicians, however, shouldn’t worry. “There are still lots of opportunities to come in and make your mark locally, regionally, or nationally within pediatric hospital medicine,” he said.

Dr. Douglas Carlson initially trained as a pediatric emergency physician and didn’t really start to think of himself as a pediatric hospitalist until a decade ago.

But today he heads up the division of pediatric hospital medicine at Washington University in St. Louis and devotes many of his off hours to ensuring that more pediatricians will choose hospital medicine as a life-long career.

“We’ve put a lot of thought into making sure these are true careers,” he said.

One of the biggest changes in the last few years has been a move away from physicians’ choosing to spend just a few years as pediatric hospitalists and moving on. Instead, those physicians who choose the specialty are staying in it longer, noted Dr. Carlson, who co-chairs a workforce committee for the Pediatric Hospital Medicine Strategic Planning Roundtable and served on the Society of Hospital Medicine’s Career Satisfaction Task Force.

Drawing physicians to pediatric hospital medicine, however, remains a challenge. Factors such as scheduling, workload, autonomy, and compensation are all important in attracting physicians to the speciality and preventing burnout. However, recognition tends to trump those issues in the eyes of most young pediatricians who are thinking about their career choices, he said.

Academic medical centers and community hospitals have been showing signs of a greater awareness of the skills that pediatric hospitalists possess that other specialists don’t bring to the table, he said. In increasing numbers, pediatric hospitalists are moving into leadership roles in their hospitals, becoming chief medical officers, for instance. And at Washington University, where Dr. Carlson works, hospital medicine became an official division within the pediatric department last September. That type of recognition is vital, he said, because many young hospitalists fear not being seen as equal to their peers in other specialties such as cardiology or gastroenterology. “But I think that’s changing rapidly,” he said.

The next step is for pediatric hospitalists to gain recognition from the American Board of Pediatrics (ABP). Dr. Carlson and others in the field are working to bring together a diverse group of pediatric hospitalists to help design the ideal pathway for certification in pediatric hospital medicine.

The American Board of Internal Medicine and the American Board of Family Medicine both recently established a “recognition of focused practice” pathway in hospital medicine for their currently certified diplomates. But so far, the ABP has been more reluctant to follow with a similar model for pediatrics, he said.

Along with persuading the leadership of the ABP to embrace the idea of certification, another major challenge is to design a pathway that continues to allow for growth in the field. Dr. Carlson said he sees value in offering 1- or 2-year fellowships in pediatric hospital medicine, which would help build the scholarly foundation of the specialty. However, he worries that it would be difficult to convince young physicians to spend those extra years in training. And it would be a challenge just to keep up with the demand. Dr. Carlson estimates that there would need to be 100-200 fellowship positions per year to keep up with the current growth in the field. “That’s a huge amount,” he said.

But he says that he is confident that these issues can be worked out in the next few years.

The double-digit growth in the field will likely slow slightly and jobs may not be quite as easy to find, he predicted. Talented physicians, however, shouldn’t worry. “There are still lots of opportunities to come in and make your mark locally, regionally, or nationally within pediatric hospital medicine,” he said.

Dr. Douglas Carlson initially trained as a pediatric emergency physician and didn’t really start to think of himself as a pediatric hospitalist until a decade ago.

But today he heads up the division of pediatric hospital medicine at Washington University in St. Louis and devotes many of his off hours to ensuring that more pediatricians will choose hospital medicine as a life-long career.

“We’ve put a lot of thought into making sure these are true careers,” he said.

One of the biggest changes in the last few years has been a move away from physicians’ choosing to spend just a few years as pediatric hospitalists and moving on. Instead, those physicians who choose the specialty are staying in it longer, noted Dr. Carlson, who co-chairs a workforce committee for the Pediatric Hospital Medicine Strategic Planning Roundtable and served on the Society of Hospital Medicine’s Career Satisfaction Task Force.

Drawing physicians to pediatric hospital medicine, however, remains a challenge. Factors such as scheduling, workload, autonomy, and compensation are all important in attracting physicians to the speciality and preventing burnout. However, recognition tends to trump those issues in the eyes of most young pediatricians who are thinking about their career choices, he said.

Academic medical centers and community hospitals have been showing signs of a greater awareness of the skills that pediatric hospitalists possess that other specialists don’t bring to the table, he said. In increasing numbers, pediatric hospitalists are moving into leadership roles in their hospitals, becoming chief medical officers, for instance. And at Washington University, where Dr. Carlson works, hospital medicine became an official division within the pediatric department last September. That type of recognition is vital, he said, because many young hospitalists fear not being seen as equal to their peers in other specialties such as cardiology or gastroenterology. “But I think that’s changing rapidly,” he said.

The next step is for pediatric hospitalists to gain recognition from the American Board of Pediatrics (ABP). Dr. Carlson and others in the field are working to bring together a diverse group of pediatric hospitalists to help design the ideal pathway for certification in pediatric hospital medicine.

The American Board of Internal Medicine and the American Board of Family Medicine both recently established a “recognition of focused practice” pathway in hospital medicine for their currently certified diplomates. But so far, the ABP has been more reluctant to follow with a similar model for pediatrics, he said.

Along with persuading the leadership of the ABP to embrace the idea of certification, another major challenge is to design a pathway that continues to allow for growth in the field. Dr. Carlson said he sees value in offering 1- or 2-year fellowships in pediatric hospital medicine, which would help build the scholarly foundation of the specialty. However, he worries that it would be difficult to convince young physicians to spend those extra years in training. And it would be a challenge just to keep up with the demand. Dr. Carlson estimates that there would need to be 100-200 fellowship positions per year to keep up with the current growth in the field. “That’s a huge amount,” he said.

But he says that he is confident that these issues can be worked out in the next few years.

The double-digit growth in the field will likely slow slightly and jobs may not be quite as easy to find, he predicted. Talented physicians, however, shouldn’t worry. “There are still lots of opportunities to come in and make your mark locally, regionally, or nationally within pediatric hospital medicine,” he said.

Next year, the federal government will launch the Center for Medicare and Medicaid Innovation, a new department to oversee the portfolio of payment pilot projects called for under the Affordable Care Act. As part of its charge, the innovation center will develop and evaluate pilot projects for new and old payment ideas that include accountable care organizations, patient-centered medical homes, bundled payments, and capitated payments. Officials at the new center, one of the Centers for Medicare and Medicaid Services (CMS), will have the authority to extend or expand projects that show the potential to improve quality or cut costs.

Stuart Guterman, who studies payment policies for the Commonwealth Fund, explains the potential and the challenges for officials leading the new innovation center.

EGMN: Why did lawmakers create this innovation center as part of the Affordable Care Act? Is it necessary?

Mr. Guterman: I think it is necessary. I think, in fact, it may turn out to be one of the most important provisions in the law. It focuses the attention of the CMS, which runs the two biggest health programs in the country, on the notion of innovation. It emphasizes the idea that we need to try new approaches to both payment and delivery of health care to get out off the path that we’re on, which is leading to ever-growing health care costs and more pressure on the health care system.

We already spend 50% more than any other country in the world on health care. Everybody points to the amount of waste in the system. But it’s harder to identify ways of actually getting rid of it and making the health care system work better for people. That’s what this innovation center was intended to do—to focus the attention of the federal government on that issue and to bring in the other parts of the health care sector to collaborate on better ways of providing care and better ways of paying for care.

EGMN: Some of the concepts – such as medical homes and capitated payments – have been tested before. What makes this effort different?

Mr. Guterman: Capitation was tried in the 1990s, but the world was a different place then. In the 1990s, we didn’t have the kinds of measures of health system performance that we have now. Also, the notion of capitating payments so that you provided a strong incentive to reduce costs got separated from the notion of providing care in an effective, efficient way. So we started out with a managed care movement that was focused on providing coordinated care for patients and we ended up with a movement that was focused primarily on reducing the costs, sometimes in arbitrary ways. Today, I think we have the tools to avoid going off that track. We may not get all the way to capitation, but there are bundled payments and other strategies that get us away from the current fee-for-service system.

In terms of the medical home, models are being tested by various private payers, Medicare is developing a demonstration project, and Medicaid is testing several models. But those efforts are fragmented, just like the rest of our health care delivery and financing systems. If we conduct these pilots individually, they are much less effective than if they can be coordinated and focused, using the same kinds of measures.

EGMN: What are the keys to making the innovation center successful?

Mr. Guterman: We need to bring together all of the health care system’s stakeholders. We are currently projected to spend between $30 trillion and $35 trillion on health care over the next 10 years. The issue is not what to cut, it’s how to use some reasonable amount of money to buy the kind of health care we think our system should produce. That requires the involvement of everyone – providers, patients, and public and private payers.

EGMN: What challenges will officials at the innovation center face in rapidly testing new payment concepts?

Mr. Guterman: It’s easy to say that everyone ought to be involved, but right now people tend to look at change as something that threatens them. We need to overcome that. We also need to have patience. A lot of these projects will take time to develop and implement, and to adjust as they go along. But Congress and the American public also need to have patience and realize these strategies will take awhile to unfold.

EGMN: Is the innovation center’s work likely to have a significant impact on lowering costs?

Mr. Guterman: Yes, though it’s hard to predict just how much. You’ve got a system now that pays for more care, more complicated care, and more invasive care, but not more appropriate and efficient care. So you’ve got to figure that if you change the focus from more to better and from more invasive to more appropriate, that you can make some difference in lowering costs.

Stuart Guterman is vice president for payment and system reform at the Commonwealth Fund in Washington, D.C. The Commonwealth Fund is a private foundation that supports research on the health care system.

Next year, the federal government will launch the Center for Medicare and Medicaid Innovation, a new department to oversee the portfolio of payment pilot projects called for under the Affordable Care Act. As part of its charge, the innovation center will develop and evaluate pilot projects for new and old payment ideas that include accountable care organizations, patient-centered medical homes, bundled payments, and capitated payments. Officials at the new center, one of the Centers for Medicare and Medicaid Services (CMS), will have the authority to extend or expand projects that show the potential to improve quality or cut costs.

Stuart Guterman, who studies payment policies for the Commonwealth Fund, explains the potential and the challenges for officials leading the new innovation center.

EGMN: Why did lawmakers create this innovation center as part of the Affordable Care Act? Is it necessary?

Mr. Guterman: I think it is necessary. I think, in fact, it may turn out to be one of the most important provisions in the law. It focuses the attention of the CMS, which runs the two biggest health programs in the country, on the notion of innovation. It emphasizes the idea that we need to try new approaches to both payment and delivery of health care to get out off the path that we’re on, which is leading to ever-growing health care costs and more pressure on the health care system.

We already spend 50% more than any other country in the world on health care. Everybody points to the amount of waste in the system. But it’s harder to identify ways of actually getting rid of it and making the health care system work better for people. That’s what this innovation center was intended to do—to focus the attention of the federal government on that issue and to bring in the other parts of the health care sector to collaborate on better ways of providing care and better ways of paying for care.

EGMN: Some of the concepts – such as medical homes and capitated payments – have been tested before. What makes this effort different?

Mr. Guterman: Capitation was tried in the 1990s, but the world was a different place then. In the 1990s, we didn’t have the kinds of measures of health system performance that we have now. Also, the notion of capitating payments so that you provided a strong incentive to reduce costs got separated from the notion of providing care in an effective, efficient way. So we started out with a managed care movement that was focused on providing coordinated care for patients and we ended up with a movement that was focused primarily on reducing the costs, sometimes in arbitrary ways. Today, I think we have the tools to avoid going off that track. We may not get all the way to capitation, but there are bundled payments and other strategies that get us away from the current fee-for-service system.

In terms of the medical home, models are being tested by various private payers, Medicare is developing a demonstration project, and Medicaid is testing several models. But those efforts are fragmented, just like the rest of our health care delivery and financing systems. If we conduct these pilots individually, they are much less effective than if they can be coordinated and focused, using the same kinds of measures.

EGMN: What are the keys to making the innovation center successful?

Mr. Guterman: We need to bring together all of the health care system’s stakeholders. We are currently projected to spend between $30 trillion and $35 trillion on health care over the next 10 years. The issue is not what to cut, it’s how to use some reasonable amount of money to buy the kind of health care we think our system should produce. That requires the involvement of everyone – providers, patients, and public and private payers.

EGMN: What challenges will officials at the innovation center face in rapidly testing new payment concepts?

Mr. Guterman: It’s easy to say that everyone ought to be involved, but right now people tend to look at change as something that threatens them. We need to overcome that. We also need to have patience. A lot of these projects will take time to develop and implement, and to adjust as they go along. But Congress and the American public also need to have patience and realize these strategies will take awhile to unfold.

EGMN: Is the innovation center’s work likely to have a significant impact on lowering costs?

Mr. Guterman: Yes, though it’s hard to predict just how much. You’ve got a system now that pays for more care, more complicated care, and more invasive care, but not more appropriate and efficient care. So you’ve got to figure that if you change the focus from more to better and from more invasive to more appropriate, that you can make some difference in lowering costs.

Stuart Guterman is vice president for payment and system reform at the Commonwealth Fund in Washington, D.C. The Commonwealth Fund is a private foundation that supports research on the health care system.

Next year, the federal government will launch the Center for Medicare and Medicaid Innovation, a new department to oversee the portfolio of payment pilot projects called for under the Affordable Care Act. As part of its charge, the innovation center will develop and evaluate pilot projects for new and old payment ideas that include accountable care organizations, patient-centered medical homes, bundled payments, and capitated payments. Officials at the new center, one of the Centers for Medicare and Medicaid Services (CMS), will have the authority to extend or expand projects that show the potential to improve quality or cut costs.

Stuart Guterman, who studies payment policies for the Commonwealth Fund, explains the potential and the challenges for officials leading the new innovation center.

EGMN: Why did lawmakers create this innovation center as part of the Affordable Care Act? Is it necessary?

Mr. Guterman: I think it is necessary. I think, in fact, it may turn out to be one of the most important provisions in the law. It focuses the attention of the CMS, which runs the two biggest health programs in the country, on the notion of innovation. It emphasizes the idea that we need to try new approaches to both payment and delivery of health care to get out off the path that we’re on, which is leading to ever-growing health care costs and more pressure on the health care system.

We already spend 50% more than any other country in the world on health care. Everybody points to the amount of waste in the system. But it’s harder to identify ways of actually getting rid of it and making the health care system work better for people. That’s what this innovation center was intended to do—to focus the attention of the federal government on that issue and to bring in the other parts of the health care sector to collaborate on better ways of providing care and better ways of paying for care.

EGMN: Some of the concepts – such as medical homes and capitated payments – have been tested before. What makes this effort different?

Mr. Guterman: Capitation was tried in the 1990s, but the world was a different place then. In the 1990s, we didn’t have the kinds of measures of health system performance that we have now. Also, the notion of capitating payments so that you provided a strong incentive to reduce costs got separated from the notion of providing care in an effective, efficient way. So we started out with a managed care movement that was focused on providing coordinated care for patients and we ended up with a movement that was focused primarily on reducing the costs, sometimes in arbitrary ways. Today, I think we have the tools to avoid going off that track. We may not get all the way to capitation, but there are bundled payments and other strategies that get us away from the current fee-for-service system.

In terms of the medical home, models are being tested by various private payers, Medicare is developing a demonstration project, and Medicaid is testing several models. But those efforts are fragmented, just like the rest of our health care delivery and financing systems. If we conduct these pilots individually, they are much less effective than if they can be coordinated and focused, using the same kinds of measures.

EGMN: What are the keys to making the innovation center successful?

Mr. Guterman: We need to bring together all of the health care system’s stakeholders. We are currently projected to spend between $30 trillion and $35 trillion on health care over the next 10 years. The issue is not what to cut, it’s how to use some reasonable amount of money to buy the kind of health care we think our system should produce. That requires the involvement of everyone – providers, patients, and public and private payers.

EGMN: What challenges will officials at the innovation center face in rapidly testing new payment concepts?

Mr. Guterman: It’s easy to say that everyone ought to be involved, but right now people tend to look at change as something that threatens them. We need to overcome that. We also need to have patience. A lot of these projects will take time to develop and implement, and to adjust as they go along. But Congress and the American public also need to have patience and realize these strategies will take awhile to unfold.

EGMN: Is the innovation center’s work likely to have a significant impact on lowering costs?

Mr. Guterman: Yes, though it’s hard to predict just how much. You’ve got a system now that pays for more care, more complicated care, and more invasive care, but not more appropriate and efficient care. So you’ve got to figure that if you change the focus from more to better and from more invasive to more appropriate, that you can make some difference in lowering costs.

Stuart Guterman is vice president for payment and system reform at the Commonwealth Fund in Washington, D.C. The Commonwealth Fund is a private foundation that supports research on the health care system.

Next year, the federal government will launch the Center for Medicare and Medicaid Innovation, a new department to oversee the portfolio of payment pilot projects called for under the Affordable Care Act. As part of its charge, the innovation center will develop and evaluate pilot projects for new and old payment ideas that include accountable care organizations, patient-centered medical homes, bundled payments, and capitated payments. Officials at the new center, one of the Centers for Medicare and Medicaid Services (CMS), will have the authority to extend or expand projects that show the potential to improve quality or cut costs.

Stuart Guterman, who studies payment policies for the Commonwealth Fund, explains the potential and the challenges for officials leading the new innovation center.

EGMN: Why did lawmakers create this innovation center as part of the Affordable Care Act? Is it necessary?

Mr. Guterman: I think it is necessary. I think, in fact, it may turn out to be one of the most important provisions in the law. It focuses the attention of the CMS, which runs the two biggest health programs in the country, on the notion of innovation. It emphasizes the idea that we need to try new approaches to both payment and delivery of health care to get out off the path that we’re on, which is leading to ever-growing health care costs and more pressure on the health care system.

We already spend 50% more than any other country in the world on health care. Everybody points to the amount of waste in the system. But it’s harder to identify ways of actually getting rid of it and making the health care system work better for people. That’s what this innovation center was intended to do—to focus the attention of the federal government on that issue and to bring in the other parts of the health care sector to collaborate on better ways of providing care and better ways of paying for care.

EGMN: Some of the concepts – such as medical homes and capitated payments – have been tested before. What makes this effort different?

Mr. Guterman: Capitation was tried in the 1990s, but the world was a different place then. In the 1990s, we didn’t have the kinds of measures of health system performance that we have now. Also, the notion of capitating payments so that you provided a strong incentive to reduce costs got separated from the notion of providing care in an effective, efficient way. So we started out with a managed care movement that was focused on providing coordinated care for patients and we ended up with a movement that was focused primarily on reducing the costs, sometimes in arbitrary ways. Today, I think we have the tools to avoid going off that track. We may not get all the way to capitation, but there are bundled payments and other strategies that get us away from the current fee-for-service system.

In terms of the medical home, models are being tested by various private payers, Medicare is developing a demonstration project, and Medicaid is testing several models. But those efforts are fragmented, just like the rest of our health care delivery and financing systems. If we conduct these pilots individually, they are much less effective than if they can be coordinated and focused, using the same kinds of measures.

EGMN: What are the keys to making the innovation center successful?

Mr. Guterman: We need to bring together all of the health care system’s stakeholders. We are currently projected to spend between $30 trillion and $35 trillion on health care over the next 10 years. The issue is not what to cut, it’s how to use some reasonable amount of money to buy the kind of health care we think our system should produce. That requires the involvement of everyone – providers, patients, and public and private payers.

EGMN: What challenges will officials at the innovation center face in rapidly testing new payment concepts?

Mr. Guterman: It’s easy to say that everyone ought to be involved, but right now people tend to look at change as something that threatens them. We need to overcome that. We also need to have patience. A lot of these projects will take time to develop and implement, and to adjust as they go along. But Congress and the American public also need to have patience and realize these strategies will take awhile to unfold.

EGMN: Is the innovation center’s work likely to have a significant impact on lowering costs?

Mr. Guterman: Yes, though it’s hard to predict just how much. You’ve got a system now that pays for more care, more complicated care, and more invasive care, but not more appropriate and efficient care. So you’ve got to figure that if you change the focus from more to better and from more invasive to more appropriate, that you can make some difference in lowering costs.

Stuart Guterman is vice president for payment and system reform at the Commonwealth Fund in Washington, D.C. The Commonwealth Fund is a private foundation that supports research on the health care system.

Next year, the federal government will launch the Center for Medicare and Medicaid Innovation, a new department to oversee the portfolio of payment pilot projects called for under the Affordable Care Act. As part of its charge, the innovation center will develop and evaluate pilot projects for new and old payment ideas that include accountable care organizations, patient-centered medical homes, bundled payments, and capitated payments. Officials at the new center, one of the Centers for Medicare and Medicaid Services (CMS), will have the authority to extend or expand projects that show the potential to improve quality or cut costs.

Stuart Guterman, who studies payment policies for the Commonwealth Fund, explains the potential and the challenges for officials leading the new innovation center.

EGMN: Why did lawmakers create this innovation center as part of the Affordable Care Act? Is it necessary?

Mr. Guterman: I think it is necessary. I think, in fact, it may turn out to be one of the most important provisions in the law. It focuses the attention of the CMS, which runs the two biggest health programs in the country, on the notion of innovation. It emphasizes the idea that we need to try new approaches to both payment and delivery of health care to get out off the path that we’re on, which is leading to ever-growing health care costs and more pressure on the health care system.

We already spend 50% more than any other country in the world on health care. Everybody points to the amount of waste in the system. But it’s harder to identify ways of actually getting rid of it and making the health care system work better for people. That’s what this innovation center was intended to do—to focus the attention of the federal government on that issue and to bring in the other parts of the health care sector to collaborate on better ways of providing care and better ways of paying for care.

EGMN: Some of the concepts – such as medical homes and capitated payments – have been tested before. What makes this effort different?

Mr. Guterman: Capitation was tried in the 1990s, but the world was a different place then. In the 1990s, we didn’t have the kinds of measures of health system performance that we have now. Also, the notion of capitating payments so that you provided a strong incentive to reduce costs got separated from the notion of providing care in an effective, efficient way. So we started out with a managed care movement that was focused on providing coordinated care for patients and we ended up with a movement that was focused primarily on reducing the costs, sometimes in arbitrary ways. Today, I think we have the tools to avoid going off that track. We may not get all the way to capitation, but there are bundled payments and other strategies that get us away from the current fee-for-service system.

In terms of the medical home, models are being tested by various private payers, Medicare is developing a demonstration project, and Medicaid is testing several models. But those efforts are fragmented, just like the rest of our health care delivery and financing systems. If we conduct these pilots individually, they are much less effective than if they can be coordinated and focused, using the same kinds of measures.

EGMN: What are the keys to making the innovation center successful?

Mr. Guterman: We need to bring together all of the health care system’s stakeholders. We are currently projected to spend between $30 trillion and $35 trillion on health care over the next 10 years. The issue is not what to cut, it’s how to use some reasonable amount of money to buy the kind of health care we think our system should produce. That requires the involvement of everyone – providers, patients, and public and private payers.

EGMN: What challenges will officials at the innovation center face in rapidly testing new payment concepts?

Mr. Guterman: It’s easy to say that everyone ought to be involved, but right now people tend to look at change as something that threatens them. We need to overcome that. We also need to have patience. A lot of these projects will take time to develop and implement, and to adjust as they go along. But Congress and the American public also need to have patience and realize these strategies will take awhile to unfold.

EGMN: Is the innovation center’s work likely to have a significant impact on lowering costs?

Mr. Guterman: Yes, though it’s hard to predict just how much. You’ve got a system now that pays for more care, more complicated care, and more invasive care, but not more appropriate and efficient care. So you’ve got to figure that if you change the focus from more to better and from more invasive to more appropriate, that you can make some difference in lowering costs.

Stuart Guterman is vice president for payment and system reform at the Commonwealth Fund in Washington, D.C. The Commonwealth Fund is a private foundation that supports research on the health care system.

Next year, the federal government will launch the Center for Medicare and Medicaid Innovation, a new department to oversee the portfolio of payment pilot projects called for under the Affordable Care Act. As part of its charge, the innovation center will develop and evaluate pilot projects for new and old payment ideas that include accountable care organizations, patient-centered medical homes, bundled payments, and capitated payments. Officials at the new center, one of the Centers for Medicare and Medicaid Services (CMS), will have the authority to extend or expand projects that show the potential to improve quality or cut costs.

Stuart Guterman, who studies payment policies for the Commonwealth Fund, explains the potential and the challenges for officials leading the new innovation center.

EGMN: Why did lawmakers create this innovation center as part of the Affordable Care Act? Is it necessary?

Mr. Guterman: I think it is necessary. I think, in fact, it may turn out to be one of the most important provisions in the law. It focuses the attention of the CMS, which runs the two biggest health programs in the country, on the notion of innovation. It emphasizes the idea that we need to try new approaches to both payment and delivery of health care to get out off the path that we’re on, which is leading to ever-growing health care costs and more pressure on the health care system.

We already spend 50% more than any other country in the world on health care. Everybody points to the amount of waste in the system. But it’s harder to identify ways of actually getting rid of it and making the health care system work better for people. That’s what this innovation center was intended to do—to focus the attention of the federal government on that issue and to bring in the other parts of the health care sector to collaborate on better ways of providing care and better ways of paying for care.

EGMN: Some of the concepts – such as medical homes and capitated payments – have been tested before. What makes this effort different?

Mr. Guterman: Capitation was tried in the 1990s, but the world was a different place then. In the 1990s, we didn’t have the kinds of measures of health system performance that we have now. Also, the notion of capitating payments so that you provided a strong incentive to reduce costs got separated from the notion of providing care in an effective, efficient way. So we started out with a managed care movement that was focused on providing coordinated care for patients and we ended up with a movement that was focused primarily on reducing the costs, sometimes in arbitrary ways. Today, I think we have the tools to avoid going off that track. We may not get all the way to capitation, but there are bundled payments and other strategies that get us away from the current fee-for-service system.

In terms of the medical home, models are being tested by various private payers, Medicare is developing a demonstration project, and Medicaid is testing several models. But those efforts are fragmented, just like the rest of our health care delivery and financing systems. If we conduct these pilots individually, they are much less effective than if they can be coordinated and focused, using the same kinds of measures.

EGMN: What are the keys to making the innovation center successful?

Mr. Guterman: We need to bring together all of the health care system’s stakeholders. We are currently projected to spend between $30 trillion and $35 trillion on health care over the next 10 years. The issue is not what to cut, it’s how to use some reasonable amount of money to buy the kind of health care we think our system should produce. That requires the involvement of everyone – providers, patients, and public and private payers.

EGMN: What challenges will officials at the innovation center face in rapidly testing new payment concepts?

Mr. Guterman: It’s easy to say that everyone ought to be involved, but right now people tend to look at change as something that threatens them. We need to overcome that. We also need to have patience. A lot of these projects will take time to develop and implement, and to adjust as they go along. But Congress and the American public also need to have patience and realize these strategies will take awhile to unfold.

EGMN: Is the innovation center’s work likely to have a significant impact on lowering costs?

Mr. Guterman: Yes, though it’s hard to predict just how much. You’ve got a system now that pays for more care, more complicated care, and more invasive care, but not more appropriate and efficient care. So you’ve got to figure that if you change the focus from more to better and from more invasive to more appropriate, that you can make some difference in lowering costs.

Stuart Guterman is vice president for payment and system reform at the Commonwealth Fund in Washington, D.C. The Commonwealth Fund is a private foundation that supports research on the health care system.

Dr. David O. Meltzer, the chief of hospital medicine at the University of Chicago, has no problem keeping busy.

When he’s not fulfilling clinical and administrative duties directly associated with his hospitalist role, he’s doing research, working on a book about hospitalists, or leading discussions about the best use of limited national funds for health research. But Dr. Meltzer loves the variety, and he thinks that young hospitalists can avoid burnout by developing diverse professional roles.

A key lesson of early research on hospitalists is that they do a better job as they gain more experience, Dr. Meltzer said. So at the University of Chicago, he and his colleagues have focused on how to design “sustainable jobs” for hospitalists. As they looked into what worked at their institution, they realized that physicians with well-defined academic niches – in administration, teaching, or research, for example – tended to be the happiest and stay the longest.

That finding led to the creation of the Hospitalist Scholars Program, which lets hospitalists get training in research and pursue scholarship in medical education early in their hospital medicine careers. The program, which typically lasts 2 years, combines masters-level courses with mentored research. Physicians in the program devote most of their time to the academic training and spend the remaining 3 months of the year doing clinical work.

After completing the program, hospitalists are prepared to pursue academic interests in the time not filled by their clinical responsibilities. That’s important, Dr. Meltzer explained, because there’s a maximum amount of time that most hospitalists can devote to clinical duties without burning out quickly. However, they still need to find other responsibilities to fill the rest of their professional time. So far the program has been a success, with the vast majority of those who complete the scholars program staying in academic hospital medicine.

Along with making hospitalist careers more sustainable on the individual level, Dr. Meltzer said he sees great potential for the program to help advance the specialty as a whole. Physicians who come out of the scholars program can incorporate research and scholarship in medical education into what they do on a daily basis, he said. Many have obtained competitive research grants or advanced into academic leadership positions.

“It’s helping to build the field as an academic field,” he said. “That will help inspire the best residents to go into hospital medicine.”

In his own career, Dr. Meltzer never has the chance to burn out because he’s always pursuing new projects. This year, he’s completing work on a research project exploring what happens to patients after they have been treated by a hospitalist and discharged. Analysis of data from many hospitals has shown that patients treated by hospitalists tend to have a shorter length of stay, but questions remain as to whether that might lead to higher readmission rates or a greater need for outpatient services. Using Medicare data, Dr. Meltzer and his colleagues found trends suggesting that hospitalists really do provide better care, and that shorter lengths of stay do not boost overall utilization, he said.

He’s also working on a book on the historical origins and development of the U.S. hospitalist movement. Funded through a grant from the Robert Wood Johnson Foundation, the project will look at why hospital medicine grew and what its origins mean for the future of the specialty. Dr. Meltzer said he’s enthusiastic about the project because a better understanding of the history of hospital medicine can help ensure the sustainability of the specialty, as all of medicine braces for the uncertainty that will come with reform of the health care system.

An early and somewhat surprising finding from his book research is that hospital medicine grew mainly because many ambulatory physicians no longer wanted the job of caring for the patient in the hospital. “Hospitalists came in and filled the gap” caused by changes in the ambulatory care setting, Dr. Meltzer said.

The wild card in charting the speciality’s future will be what happens with health care reform, particularly the bundling of payments for inpatient and outpatient services. “We’re going to be in a pretty uncertain environment in hospital medicine for the next few years,” he said.

Dr. David O. Meltzer, the chief of hospital medicine at the University of Chicago, has no problem keeping busy.

When he’s not fulfilling clinical and administrative duties directly associated with his hospitalist role, he’s doing research, working on a book about hospitalists, or leading discussions about the best use of limited national funds for health research. But Dr. Meltzer loves the variety, and he thinks that young hospitalists can avoid burnout by developing diverse professional roles.

A key lesson of early research on hospitalists is that they do a better job as they gain more experience, Dr. Meltzer said. So at the University of Chicago, he and his colleagues have focused on how to design “sustainable jobs” for hospitalists. As they looked into what worked at their institution, they realized that physicians with well-defined academic niches – in administration, teaching, or research, for example – tended to be the happiest and stay the longest.

That finding led to the creation of the Hospitalist Scholars Program, which lets hospitalists get training in research and pursue scholarship in medical education early in their hospital medicine careers. The program, which typically lasts 2 years, combines masters-level courses with mentored research. Physicians in the program devote most of their time to the academic training and spend the remaining 3 months of the year doing clinical work.

After completing the program, hospitalists are prepared to pursue academic interests in the time not filled by their clinical responsibilities. That’s important, Dr. Meltzer explained, because there’s a maximum amount of time that most hospitalists can devote to clinical duties without burning out quickly. However, they still need to find other responsibilities to fill the rest of their professional time. So far the program has been a success, with the vast majority of those who complete the scholars program staying in academic hospital medicine.

Along with making hospitalist careers more sustainable on the individual level, Dr. Meltzer said he sees great potential for the program to help advance the specialty as a whole. Physicians who come out of the scholars program can incorporate research and scholarship in medical education into what they do on a daily basis, he said. Many have obtained competitive research grants or advanced into academic leadership positions.

“It’s helping to build the field as an academic field,” he said. “That will help inspire the best residents to go into hospital medicine.”

In his own career, Dr. Meltzer never has the chance to burn out because he’s always pursuing new projects. This year, he’s completing work on a research project exploring what happens to patients after they have been treated by a hospitalist and discharged. Analysis of data from many hospitals has shown that patients treated by hospitalists tend to have a shorter length of stay, but questions remain as to whether that might lead to higher readmission rates or a greater need for outpatient services. Using Medicare data, Dr. Meltzer and his colleagues found trends suggesting that hospitalists really do provide better care, and that shorter lengths of stay do not boost overall utilization, he said.

He’s also working on a book on the historical origins and development of the U.S. hospitalist movement. Funded through a grant from the Robert Wood Johnson Foundation, the project will look at why hospital medicine grew and what its origins mean for the future of the specialty. Dr. Meltzer said he’s enthusiastic about the project because a better understanding of the history of hospital medicine can help ensure the sustainability of the specialty, as all of medicine braces for the uncertainty that will come with reform of the health care system.

An early and somewhat surprising finding from his book research is that hospital medicine grew mainly because many ambulatory physicians no longer wanted the job of caring for the patient in the hospital. “Hospitalists came in and filled the gap” caused by changes in the ambulatory care setting, Dr. Meltzer said.

The wild card in charting the speciality’s future will be what happens with health care reform, particularly the bundling of payments for inpatient and outpatient services. “We’re going to be in a pretty uncertain environment in hospital medicine for the next few years,” he said.

Dr. David O. Meltzer, the chief of hospital medicine at the University of Chicago, has no problem keeping busy.

When he’s not fulfilling clinical and administrative duties directly associated with his hospitalist role, he’s doing research, working on a book about hospitalists, or leading discussions about the best use of limited national funds for health research. But Dr. Meltzer loves the variety, and he thinks that young hospitalists can avoid burnout by developing diverse professional roles.

A key lesson of early research on hospitalists is that they do a better job as they gain more experience, Dr. Meltzer said. So at the University of Chicago, he and his colleagues have focused on how to design “sustainable jobs” for hospitalists. As they looked into what worked at their institution, they realized that physicians with well-defined academic niches – in administration, teaching, or research, for example – tended to be the happiest and stay the longest.

That finding led to the creation of the Hospitalist Scholars Program, which lets hospitalists get training in research and pursue scholarship in medical education early in their hospital medicine careers. The program, which typically lasts 2 years, combines masters-level courses with mentored research. Physicians in the program devote most of their time to the academic training and spend the remaining 3 months of the year doing clinical work.

After completing the program, hospitalists are prepared to pursue academic interests in the time not filled by their clinical responsibilities. That’s important, Dr. Meltzer explained, because there’s a maximum amount of time that most hospitalists can devote to clinical duties without burning out quickly. However, they still need to find other responsibilities to fill the rest of their professional time. So far the program has been a success, with the vast majority of those who complete the scholars program staying in academic hospital medicine.

Along with making hospitalist careers more sustainable on the individual level, Dr. Meltzer said he sees great potential for the program to help advance the specialty as a whole. Physicians who come out of the scholars program can incorporate research and scholarship in medical education into what they do on a daily basis, he said. Many have obtained competitive research grants or advanced into academic leadership positions.

“It’s helping to build the field as an academic field,” he said. “That will help inspire the best residents to go into hospital medicine.”

In his own career, Dr. Meltzer never has the chance to burn out because he’s always pursuing new projects. This year, he’s completing work on a research project exploring what happens to patients after they have been treated by a hospitalist and discharged. Analysis of data from many hospitals has shown that patients treated by hospitalists tend to have a shorter length of stay, but questions remain as to whether that might lead to higher readmission rates or a greater need for outpatient services. Using Medicare data, Dr. Meltzer and his colleagues found trends suggesting that hospitalists really do provide better care, and that shorter lengths of stay do not boost overall utilization, he said.

He’s also working on a book on the historical origins and development of the U.S. hospitalist movement. Funded through a grant from the Robert Wood Johnson Foundation, the project will look at why hospital medicine grew and what its origins mean for the future of the specialty. Dr. Meltzer said he’s enthusiastic about the project because a better understanding of the history of hospital medicine can help ensure the sustainability of the specialty, as all of medicine braces for the uncertainty that will come with reform of the health care system.

An early and somewhat surprising finding from his book research is that hospital medicine grew mainly because many ambulatory physicians no longer wanted the job of caring for the patient in the hospital. “Hospitalists came in and filled the gap” caused by changes in the ambulatory care setting, Dr. Meltzer said.

The wild card in charting the speciality’s future will be what happens with health care reform, particularly the bundling of payments for inpatient and outpatient services. “We’re going to be in a pretty uncertain environment in hospital medicine for the next few years,” he said.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.

Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.

“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.

Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.

“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.

Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.

“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.

Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.

“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.

Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.

“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.

Naseem S. Miller contributed to this report.

Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.

“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).

In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.

While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.

Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.

Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.

The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.

“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.

Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.

One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.

Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.

“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”

There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.

ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law. The innovation center has broad authority to test new payment ideas and will launch in January 2011.

Finally, the Affordable Care Act includes a pediatric ACO demonstration project that allows states to recognize pediatric medical providers as ACOs and to award incentive payments through Medicaid. That project is also expected to launch in January 2012.

Since the passage of the Affordable Care Act, there’s been a “flurry of activity” going on around the country, similar to what happened in the early 1990s around the growth of HMOs and capitation, said Dr. Crosson of the Kaiser Permanente Institute, who is also a pediatrician. “All over the country, hospital boards are going off with their medical staffs and asking the question, ‘Do we want to become an ACO?’?”

In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Other will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. The real question, Dr. Crosson noted, is not whether various models can be designed, but which ones will work best. And for that, he said, only time will tell.

But he added that pediatricians will have a role, especially if they have had success in transitioning to a patient-centered medical home practice. The type of care coordination that happens at the individual practice level is the same type of capability a physician will need to be successful within an ACO, he said.

“I think there’s room in this for virtually everyone to be in the game and try to get it to work,” Dr. Crosson said.

As the ACO concept develops, pediatricians may find that they are getting a lot more attention from hospitals that are interested in developing closer, more collaborative relationships with them, said Dr. Allen of Nationwide Children’s Hospital.

“I think [pediatricians] are going to find themselves to be incredibly popular,” Dr. Allen said.

The NCQA has convened a task force to study the concept of ACOs, and this month it plans to release its recommendations for what qualifying criteria these organizations should meet.

The task force includes representatives from organizations that consider themselves to be ACOs or that are developing plans to launch one. The diverse group has been working on setting out specific criteria – from governance structures to the ability to manage financial risk – that will help ACOs to succeed in the coming years.

“The idea [of ACOs] is mom and apple pie, and it’s terrific to talk about in its generalities,” said Tricia Barrett, vice president of product development at the NCQA. “But as soon as you start talking about specifics, you realize that nobody’s talking about the same thing.”

Over the past few months, task force members have delved into the details and found some common ground, she said, recognizing that there will be a variety of ways to run an ACO. For example, there is consensus within the task force that primary care and the principles of the patient-centered medical home need to be at the foundation of the ACO. The extent to which specialists and hospitals are part of the same legal entity, rather than contracted with primary care physicians, will depend on the dynamics in individual marketplaces, she said.

The task force is also making headway on the specific qualifying criteria that ACOs should meet to demonstrate that they are set up for success. For example, task force members generally agree that there should be rules around the composition of provider networks within ACOs. This would ensure that patients have a certain level of access to both primary care and specialist physicians, and that the ACO is able to support the full spectrum of patient needs.

Performance measurement will also be a critical way to evaluate ACOs. However, getting to reliable, comparable performance results related to these organizations will take some time, Ms. Barrett said.

The NCQA task force members are also focused on ensuring that there are consumer protections built into the ACO structure. Consumers need to be considered in the design and policies of an ACO so that they have a full understanding of what their obligations and rights are, Ms. Barrett said.

Naseem S. Miller contributed to this report.

Dr. Lori Heim is anything but a typical hospitalist.

She came to the field after working for many years as a family physician in the outpatient arena, and she now enjoys the chance to focus on quality and have time for interests outside of her own practice. And when Dr. Heim isn’t in the hospital, she’s likely at the airport, on her way to another meeting with lawmakers or physicians to discuss health reform, workforce issues, or the Medicare payment formula. As the current president of the American Academy of Family Physicians, Dr. Heim brings a unique perspective to her Laurinburg, N.C., hospital.

Dr. Heim is the first family physician to join the new hospital medicine program at Scotland Memorial Hospital. Currently, she practices alongside four internists and two family nurse practitioners as part of the growing program. Nationwide, family physicians are a minority in the hospitalist community. The Society of Hospital Medicine reports that fewer than 4% of hospitalists are trained in family medicine, compared with more than 80% of practicing hospitalists who were trained in general internal medicine.

Similarly, only about 4% of AAFP members were working as hospitalists in 2009. Whether that indicates a lack of interest by hospitals or family physicians is unclear. But Dr. Heim said hospital medicine can be a good option for family physicians, even if it’s not a career-long choice.

For some, it is simply a love of hospital medicine that drives the career choice. For others, it may represent a chance to get away from the administrative issues that plague many family physicians in private practice. And for others, it is a pragmatic way to get a better balance in their work and family lives, she said.

“I think what this shows is the incredible opportunity that [physicians] have within family medicine to tailor different parts of medicine, different focuses, at different times of their career,” she said.

For their part, family physicians can bring additional skills to the hospital medicine world. For example, hospital medicine groups with family physicians can expand the care they provide to children. And Dr. Heim said that when she is called to a medicine consult with obstetric and gynecology patients, she is glad for her broad-based training. “I’ve dealt with a lot of the complications with regard to pregnancy and women’s issues,” she said. “It’s very familiar territory given our training.”

Dr. Heim said her own experience as a hospitalist over the last 18 months has really opened her eyes to systemwide issues that can result in poor outcomes for patients. Although family physicians often do a good job during the face-to-face visit, there aren’t good systems to help patients outside that encounter, she said. And patients who can’t get an appointment to see their regular doctor, or who don’t have a regular physician, often end up hospitalized or readmitted.

But Dr. Heim is using her position as AAFP president to draw attention to some of these gaps in care. She tells lawmakers and the media about her firsthand experiences in the hospital, highlighting how conditions that can be cheaply and easily treated in the primary care setting, such as hypertension, can become expensive complications by the time they reach her in the hospital.

After her official leadership role with AAFP wraps up in a few years, Dr. Heim said she hopes to bring some of the innovative solutions she’s seen while traveling around the country back to her North Carolina hospital. She looks forward to taking concrete steps on concepts like the medical home neighborhood, which envisions more coordinated patient care with roles for the hospital, the hospitalist, the primary care physician, subspecialists, and the community.

Dr. Lori Heim is anything but a typical hospitalist.

She came to the field after working for many years as a family physician in the outpatient arena, and she now enjoys the chance to focus on quality and have time for interests outside of her own practice. And when Dr. Heim isn’t in the hospital, she’s likely at the airport, on her way to another meeting with lawmakers or physicians to discuss health reform, workforce issues, or the Medicare payment formula. As the current president of the American Academy of Family Physicians, Dr. Heim brings a unique perspective to her Laurinburg, N.C., hospital.

Dr. Heim is the first family physician to join the new hospital medicine program at Scotland Memorial Hospital. Currently, she practices alongside four internists and two family nurse practitioners as part of the growing program. Nationwide, family physicians are a minority in the hospitalist community. The Society of Hospital Medicine reports that fewer than 4% of hospitalists are trained in family medicine, compared with more than 80% of practicing hospitalists who were trained in general internal medicine.

Similarly, only about 4% of AAFP members were working as hospitalists in 2009. Whether that indicates a lack of interest by hospitals or family physicians is unclear. But Dr. Heim said hospital medicine can be a good option for family physicians, even if it’s not a career-long choice.

For some, it is simply a love of hospital medicine that drives the career choice. For others, it may represent a chance to get away from the administrative issues that plague many family physicians in private practice. And for others, it is a pragmatic way to get a better balance in their work and family lives, she said.

“I think what this shows is the incredible opportunity that [physicians] have within family medicine to tailor different parts of medicine, different focuses, at different times of their career,” she said.

For their part, family physicians can bring additional skills to the hospital medicine world. For example, hospital medicine groups with family physicians can expand the care they provide to children. And Dr. Heim said that when she is called to a medicine consult with obstetric and gynecology patients, she is glad for her broad-based training. “I’ve dealt with a lot of the complications with regard to pregnancy and women’s issues,” she said. “It’s very familiar territory given our training.”

Dr. Heim said her own experience as a hospitalist over the last 18 months has really opened her eyes to systemwide issues that can result in poor outcomes for patients. Although family physicians often do a good job during the face-to-face visit, there aren’t good systems to help patients outside that encounter, she said. And patients who can’t get an appointment to see their regular doctor, or who don’t have a regular physician, often end up hospitalized or readmitted.

But Dr. Heim is using her position as AAFP president to draw attention to some of these gaps in care. She tells lawmakers and the media about her firsthand experiences in the hospital, highlighting how conditions that can be cheaply and easily treated in the primary care setting, such as hypertension, can become expensive complications by the time they reach her in the hospital.

After her official leadership role with AAFP wraps up in a few years, Dr. Heim said she hopes to bring some of the innovative solutions she’s seen while traveling around the country back to her North Carolina hospital. She looks forward to taking concrete steps on concepts like the medical home neighborhood, which envisions more coordinated patient care with roles for the hospital, the hospitalist, the primary care physician, subspecialists, and the community.

Dr. Lori Heim is anything but a typical hospitalist.

She came to the field after working for many years as a family physician in the outpatient arena, and she now enjoys the chance to focus on quality and have time for interests outside of her own practice. And when Dr. Heim isn’t in the hospital, she’s likely at the airport, on her way to another meeting with lawmakers or physicians to discuss health reform, workforce issues, or the Medicare payment formula. As the current president of the American Academy of Family Physicians, Dr. Heim brings a unique perspective to her Laurinburg, N.C., hospital.

Dr. Heim is the first family physician to join the new hospital medicine program at Scotland Memorial Hospital. Currently, she practices alongside four internists and two family nurse practitioners as part of the growing program. Nationwide, family physicians are a minority in the hospitalist community. The Society of Hospital Medicine reports that fewer than 4% of hospitalists are trained in family medicine, compared with more than 80% of practicing hospitalists who were trained in general internal medicine.

Similarly, only about 4% of AAFP members were working as hospitalists in 2009. Whether that indicates a lack of interest by hospitals or family physicians is unclear. But Dr. Heim said hospital medicine can be a good option for family physicians, even if it’s not a career-long choice.

For some, it is simply a love of hospital medicine that drives the career choice. For others, it may represent a chance to get away from the administrative issues that plague many family physicians in private practice. And for others, it is a pragmatic way to get a better balance in their work and family lives, she said.

“I think what this shows is the incredible opportunity that [physicians] have within family medicine to tailor different parts of medicine, different focuses, at different times of their career,” she said.

For their part, family physicians can bring additional skills to the hospital medicine world. For example, hospital medicine groups with family physicians can expand the care they provide to children. And Dr. Heim said that when she is called to a medicine consult with obstetric and gynecology patients, she is glad for her broad-based training. “I’ve dealt with a lot of the complications with regard to pregnancy and women’s issues,” she said. “It’s very familiar territory given our training.”

Dr. Heim said her own experience as a hospitalist over the last 18 months has really opened her eyes to systemwide issues that can result in poor outcomes for patients. Although family physicians often do a good job during the face-to-face visit, there aren’t good systems to help patients outside that encounter, she said. And patients who can’t get an appointment to see their regular doctor, or who don’t have a regular physician, often end up hospitalized or readmitted.

But Dr. Heim is using her position as AAFP president to draw attention to some of these gaps in care. She tells lawmakers and the media about her firsthand experiences in the hospital, highlighting how conditions that can be cheaply and easily treated in the primary care setting, such as hypertension, can become expensive complications by the time they reach her in the hospital.

After her official leadership role with AAFP wraps up in a few years, Dr. Heim said she hopes to bring some of the innovative solutions she’s seen while traveling around the country back to her North Carolina hospital. She looks forward to taking concrete steps on concepts like the medical home neighborhood, which envisions more coordinated patient care with roles for the hospital, the hospitalist, the primary care physician, subspecialists, and the community.

New federal regulations mandated by the Affordable Care Act will give patients new rights to appeal claims denials made by their health plans.

The rules, announced on July 22, will allow consumers in new health plans to appeal decisions both through their insurers' internal processes and to an outside, independent entity. While most health plans already provide for an internal appeals process, not all offer an external review of plan decisions, according to the Department of Health and Human Services. The types of appeals processes often depend on individual state laws.

HHS officials estimate that in 2011 there will be 31 million people in new employer plans and another 10 million in new individual market plans who will be able to take advantage of these new appeals opportunities. By 2013, that number is expected to grow to 88 million people. The rules do not apply to grandfathered health plans.

Under the new rules, health plans that begin on or after Sept. 23, 2010 must have an internal appeals process that allows consumers to appeal whenever the plan denies a claim for a covered service or rescinds coverage. The internal appeals process must also offer consumers detailed information about the grounds for their denial and information on how to file an appeal.

The rules aim to make internal appeals more objective by ensuring that the person considering the appeal does not have a conflict of interest. For example, the health plan is not allowed to offer financial incentives to employees based on the number of claims that are denied. Health plans also will have to provide an expedited appeals process, which would allow urgent cases to be reviewed within 24 hours.

The new federal appeals regulations also standardize rules for external appeals. Currently, 44 states require health plans to have some type of external appeal but those processes vary, the HHS reported. Under the federal rules, health plans must provide clear information about external appeals and expedited access to the process. Decisions made through external appeals are binding under the new rules.

New federal regulations mandated by the Affordable Care Act will give patients new rights to appeal claims denials made by their health plans.

The rules, announced on July 22, will allow consumers in new health plans to appeal decisions both through their insurers' internal processes and to an outside, independent entity. While most health plans already provide for an internal appeals process, not all offer an external review of plan decisions, according to the Department of Health and Human Services. The types of appeals processes often depend on individual state laws.

HHS officials estimate that in 2011 there will be 31 million people in new employer plans and another 10 million in new individual market plans who will be able to take advantage of these new appeals opportunities. By 2013, that number is expected to grow to 88 million people. The rules do not apply to grandfathered health plans.

Under the new rules, health plans that begin on or after Sept. 23, 2010 must have an internal appeals process that allows consumers to appeal whenever the plan denies a claim for a covered service or rescinds coverage. The internal appeals process must also offer consumers detailed information about the grounds for their denial and information on how to file an appeal.

The rules aim to make internal appeals more objective by ensuring that the person considering the appeal does not have a conflict of interest. For example, the health plan is not allowed to offer financial incentives to employees based on the number of claims that are denied. Health plans also will have to provide an expedited appeals process, which would allow urgent cases to be reviewed within 24 hours.

The new federal appeals regulations also standardize rules for external appeals. Currently, 44 states require health plans to have some type of external appeal but those processes vary, the HHS reported. Under the federal rules, health plans must provide clear information about external appeals and expedited access to the process. Decisions made through external appeals are binding under the new rules.

New federal regulations mandated by the Affordable Care Act will give patients new rights to appeal claims denials made by their health plans.

The rules, announced on July 22, will allow consumers in new health plans to appeal decisions both through their insurers' internal processes and to an outside, independent entity. While most health plans already provide for an internal appeals process, not all offer an external review of plan decisions, according to the Department of Health and Human Services. The types of appeals processes often depend on individual state laws.

HHS officials estimate that in 2011 there will be 31 million people in new employer plans and another 10 million in new individual market plans who will be able to take advantage of these new appeals opportunities. By 2013, that number is expected to grow to 88 million people. The rules do not apply to grandfathered health plans.

Under the new rules, health plans that begin on or after Sept. 23, 2010 must have an internal appeals process that allows consumers to appeal whenever the plan denies a claim for a covered service or rescinds coverage. The internal appeals process must also offer consumers detailed information about the grounds for their denial and information on how to file an appeal.

The rules aim to make internal appeals more objective by ensuring that the person considering the appeal does not have a conflict of interest. For example, the health plan is not allowed to offer financial incentives to employees based on the number of claims that are denied. Health plans also will have to provide an expedited appeals process, which would allow urgent cases to be reviewed within 24 hours.

The new federal appeals regulations also standardize rules for external appeals. Currently, 44 states require health plans to have some type of external appeal but those processes vary, the HHS reported. Under the federal rules, health plans must provide clear information about external appeals and expedited access to the process. Decisions made through external appeals are binding under the new rules.

Patients could gain greater access to their health information and have more power to limit disclosures of certain personal information to health plans under a new proposal from the Health and Human Services department.

The new requirements, announced on July 8, are aimed at beefing up privacy and security, as the Obama administration pushes to get more physicians using electronic health records over the next few years.

“The benefits of health IT can only be fully realized if patients and providers are confident that electronic health information is kept private and secure at all times,” Georgina Verdugo, director of the HHS Office for Civil Rights, said in a statement. “This proposed rule strengthens the privacy and security of health information, and is an integral piece of the administration's efforts to broaden the use of health information technology in health care today.”

The proposal alters the Health Insurance Portability and Accountability Act (HIPAA) rules by setting new limits on the use of disclosure of protected health information for marketing and fundraising and by requiring business associates of HIPAA-covered entities to follow most of the same rules that covered entities follow. The proposal would also bar the sale of protected health information without explicit authorization from the patient.

The proposal also implements elements of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which requires physicians and other covered entities to grant patient requests to restrict certain information from their health plans.

For example, the proposed rule states that patients must be allowed to restrict protected health information if it is related only to a service for which the patient paid in full and is not otherwise required by law to be reported.

Individuals can provide comments on the rule for 60 days, beginning on July 14. Along with the release of the proposed regulation, HHS has also launched a new Web site (www.hhs.gov/healthprivacy/index.html

Patients could gain greater access to their health information and have more power to limit disclosures of certain personal information to health plans under a new proposal from the Health and Human Services department.

The new requirements, announced on July 8, are aimed at beefing up privacy and security, as the Obama administration pushes to get more physicians using electronic health records over the next few years.

“The benefits of health IT can only be fully realized if patients and providers are confident that electronic health information is kept private and secure at all times,” Georgina Verdugo, director of the HHS Office for Civil Rights, said in a statement. “This proposed rule strengthens the privacy and security of health information, and is an integral piece of the administration's efforts to broaden the use of health information technology in health care today.”

The proposal alters the Health Insurance Portability and Accountability Act (HIPAA) rules by setting new limits on the use of disclosure of protected health information for marketing and fundraising and by requiring business associates of HIPAA-covered entities to follow most of the same rules that covered entities follow. The proposal would also bar the sale of protected health information without explicit authorization from the patient.

The proposal also implements elements of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which requires physicians and other covered entities to grant patient requests to restrict certain information from their health plans.

For example, the proposed rule states that patients must be allowed to restrict protected health information if it is related only to a service for which the patient paid in full and is not otherwise required by law to be reported.

Individuals can provide comments on the rule for 60 days, beginning on July 14. Along with the release of the proposed regulation, HHS has also launched a new Web site (www.hhs.gov/healthprivacy/index.html

Patients could gain greater access to their health information and have more power to limit disclosures of certain personal information to health plans under a new proposal from the Health and Human Services department.

The new requirements, announced on July 8, are aimed at beefing up privacy and security, as the Obama administration pushes to get more physicians using electronic health records over the next few years.

“The benefits of health IT can only be fully realized if patients and providers are confident that electronic health information is kept private and secure at all times,” Georgina Verdugo, director of the HHS Office for Civil Rights, said in a statement. “This proposed rule strengthens the privacy and security of health information, and is an integral piece of the administration's efforts to broaden the use of health information technology in health care today.”

The proposal alters the Health Insurance Portability and Accountability Act (HIPAA) rules by setting new limits on the use of disclosure of protected health information for marketing and fundraising and by requiring business associates of HIPAA-covered entities to follow most of the same rules that covered entities follow. The proposal would also bar the sale of protected health information without explicit authorization from the patient.

The proposal also implements elements of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which requires physicians and other covered entities to grant patient requests to restrict certain information from their health plans.

For example, the proposed rule states that patients must be allowed to restrict protected health information if it is related only to a service for which the patient paid in full and is not otherwise required by law to be reported.

Individuals can provide comments on the rule for 60 days, beginning on July 14. Along with the release of the proposed regulation, HHS has also launched a new Web site (www.hhs.gov/healthprivacy/index.html

New health plans will soon be required to offer a range of recommended preventive health services to patients free of charge under the Affordable Care Act.

The requirements will affect new private health plans in the individual and group markets starting with plan years that begin on or after Sept. 23. The Health and Human Services department estimates that in 2011, the rules will impact about 30 million people in group health plans and another 10 million in individual market plans. The rules do not apply to grandfathered plans.

The administration released an interim final regulation detailing the new requirements on July 14. Under the final rule, health plans may not collect copayments, coinsurance, or deductibles for various recommended preventive services. But they may collect fees for the associated office visit if the preventive service was not the primary purpose of the visit. Patients may also incur cost sharing if they go out of network for the screenings.

The covered services include those given an evidence rating of “A” or “B” from the U.S. Preventive Services Task Force. Those services include breast and colon cancer screenings, diabetes screenings, blood pressure and cholesterol testing, and screening for vitamin deficiencies during pregnancy. Tobacco cessation counseling is also given a high evidence rating by the task force and would be covered under the new rule.

Health plans will have time to begin covering newly recommended services. For recommendations that have been in effect for less than a year, plans will have 1 year to comply after the effective date, according to the interim final rule.

Health plans will also be required to cover the list of adult and childhood vaccines recommended by the Advisory Committee on Immunization Practices. For children, the rule requires health plans to cover all preventive care recommended under the Bright Futures guidelines. The guidelines include screenings, developmental assessments, immunizations, and regular well-child visits from birth to age 21 years. These guidelines were developed jointly by the Health Resources and Services Administration and the American Academy of Pediatrics.

The rule calls for coverage of additional preventive services for women, which will be developed by an independent group of experts. The recommendations from that group are expected by Aug. 1, 2011. There was no word from HHS on whether those recommendations are likely to include coverage for contraceptives, something many reproductive health advocates have been lobbying for in recent months.

HHS officials expect that the move to expand coverage and eliminate out-of-pocket costs for these services will decrease costs for many Americans, especially those at high risk for certain health conditions. The change also is expected to increase premiums for enrollees in nongrandfathered plans. The federal government estimates that premiums in the affected plans could increase about 1.5% on average.

The recommended preventive services are listed at www.healthcare.gov/center/regulations/prevention/recommendations.html

New health plans will soon be required to offer a range of recommended preventive health services to patients free of charge under the Affordable Care Act.

The requirements will affect new private health plans in the individual and group markets starting with plan years that begin on or after Sept. 23. The Health and Human Services department estimates that in 2011, the rules will impact about 30 million people in group health plans and another 10 million in individual market plans. The rules do not apply to grandfathered plans.

The administration released an interim final regulation detailing the new requirements on July 14. Under the final rule, health plans may not collect copayments, coinsurance, or deductibles for various recommended preventive services. But they may collect fees for the associated office visit if the preventive service was not the primary purpose of the visit. Patients may also incur cost sharing if they go out of network for the screenings.

The covered services include those given an evidence rating of “A” or “B” from the U.S. Preventive Services Task Force. Those services include breast and colon cancer screenings, diabetes screenings, blood pressure and cholesterol testing, and screening for vitamin deficiencies during pregnancy. Tobacco cessation counseling is also given a high evidence rating by the task force and would be covered under the new rule.

Health plans will have time to begin covering newly recommended services. For recommendations that have been in effect for less than a year, plans will have 1 year to comply after the effective date, according to the interim final rule.

Health plans will also be required to cover the list of adult and childhood vaccines recommended by the Advisory Committee on Immunization Practices. For children, the rule requires health plans to cover all preventive care recommended under the Bright Futures guidelines. The guidelines include screenings, developmental assessments, immunizations, and regular well-child visits from birth to age 21 years. These guidelines were developed jointly by the Health Resources and Services Administration and the American Academy of Pediatrics.

The rule calls for coverage of additional preventive services for women, which will be developed by an independent group of experts. The recommendations from that group are expected by Aug. 1, 2011. There was no word from HHS on whether those recommendations are likely to include coverage for contraceptives, something many reproductive health advocates have been lobbying for in recent months.

HHS officials expect that the move to expand coverage and eliminate out-of-pocket costs for these services will decrease costs for many Americans, especially those at high risk for certain health conditions. The change also is expected to increase premiums for enrollees in nongrandfathered plans. The federal government estimates that premiums in the affected plans could increase about 1.5% on average.

The recommended preventive services are listed at www.healthcare.gov/center/regulations/prevention/recommendations.html

New health plans will soon be required to offer a range of recommended preventive health services to patients free of charge under the Affordable Care Act.

The requirements will affect new private health plans in the individual and group markets starting with plan years that begin on or after Sept. 23. The Health and Human Services department estimates that in 2011, the rules will impact about 30 million people in group health plans and another 10 million in individual market plans. The rules do not apply to grandfathered plans.

The administration released an interim final regulation detailing the new requirements on July 14. Under the final rule, health plans may not collect copayments, coinsurance, or deductibles for various recommended preventive services. But they may collect fees for the associated office visit if the preventive service was not the primary purpose of the visit. Patients may also incur cost sharing if they go out of network for the screenings.

The covered services include those given an evidence rating of “A” or “B” from the U.S. Preventive Services Task Force. Those services include breast and colon cancer screenings, diabetes screenings, blood pressure and cholesterol testing, and screening for vitamin deficiencies during pregnancy. Tobacco cessation counseling is also given a high evidence rating by the task force and would be covered under the new rule.

Health plans will have time to begin covering newly recommended services. For recommendations that have been in effect for less than a year, plans will have 1 year to comply after the effective date, according to the interim final rule.

Health plans will also be required to cover the list of adult and childhood vaccines recommended by the Advisory Committee on Immunization Practices. For children, the rule requires health plans to cover all preventive care recommended under the Bright Futures guidelines. The guidelines include screenings, developmental assessments, immunizations, and regular well-child visits from birth to age 21 years. These guidelines were developed jointly by the Health Resources and Services Administration and the American Academy of Pediatrics.

The rule calls for coverage of additional preventive services for women, which will be developed by an independent group of experts. The recommendations from that group are expected by Aug. 1, 2011. There was no word from HHS on whether those recommendations are likely to include coverage for contraceptives, something many reproductive health advocates have been lobbying for in recent months.

HHS officials expect that the move to expand coverage and eliminate out-of-pocket costs for these services will decrease costs for many Americans, especially those at high risk for certain health conditions. The change also is expected to increase premiums for enrollees in nongrandfathered plans. The federal government estimates that premiums in the affected plans could increase about 1.5% on average.

The recommended preventive services are listed at www.healthcare.gov/center/regulations/prevention/recommendations.html