Accountable Care Organizations and Medicaid

We recently heard Jonathan Blum, Deputy Administrator and Director of the Centers for Medicare at CMS speak regarding ACOs. He was discussing “Accountable Care Organizations and the Affordable Care Act,” and answered questions from an audience at a conference.  The first Medicaid ACO may be authorized in New Jersey in a bill before the NJ Legislature. It is an attempt to reach under served, poor who often cannot access health reform programs, which is one type of ACO that may evolve.

Some of the questions included:

  • Regarding geographic exclusivity for ACOs Blum acknowledged the difficulties presented by overlap, but also pointed to the negative implications of exclusivity on competition.
  • Will physicians be able to join more than one ACO? CMS is considering rules that may be different for primary care physicians and specialists, but Blum said that overlapping provider networks will make the computation of gain difficult when gains haring is implemented.
  • CMS anticipates a variety of models for ACOs, but stressed that no ACO would function without physician buy-in.

Accountable Care standards may fluid for some time, however it is clear that there will be a need for core competencies in population management, coordination of care and other areas for an ACO to function effectively.  Blum emphasized that CMS will be looking for innovative models, with different payment systems, and with different “on ramps” to formation and approval.  It was also acknowledged that improving quality and reducing cost through coordination of care will at times be at odds with and the Accountable Care Act’s continued focus on patient choice of providers.

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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.