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WASHINGTON, DC 20001‐6704 
Phone: 202.787.1230 
Fax: 202.480.1227 

     June 6, 2011                                                                             

     Donald Berwick, MD, MPP
     Centers for Medicare and Medicaid Services
     Department of Health and Human Services
     Room 445-F, Hubert H. Humphrey Building
     200 Independence Avenue SW
     Washington, DC 20201

     Re:       CMS-1345-P: Medicare Program; Medicare Shared Savings Program: Accountable Care

     Dear Administrator Berwick:

     On behalf of The Society of Thoracic Surgeons (STS), the largest organization representing
     cardiothoracic surgeons in the United States and the world, I am writing to comment on CMS-1345-P:
     Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations (ACO)
     proposed rule. STS represents surgeons who perform lifesaving procedures for the heart, lung, and
     esophagus as well as other surgical procedures of the chest. We appreciate the opportunity to share our

     In summary, STS believes that the ACO proposed rule should be modified to:

              Remove potential barriers to participation by cardiothoracic surgeons in the new ACO model;
              Better define the role of specialists in the administration of the ACO; and
              Include specialty-specific measures in ACO quality reporting, to include participation in
               systematic databases for cardiac and general thoracic surgery, as well as other registry-based
               process and outcomes measures.

     STS believes that the quality improvement initiatives contained in the Affordable Care Act (ACA) hold
     a great deal of promise to help the medical community to improve the quality of patient care and patient
     outcomes. We recognize that successful participation means that physicians throughout the country must
     become familiar with the Medicare Shared Savings Program (Shared Savings Program) and that many
     physicians will have to change their organizational structures and processes of care in order to
     participate in new delivery and payment system reforms. We support health care delivery system reform
     that encourages providers to collaborate and provide patient-centered care that improves quality and
     results in cost savings. Specifically, we have supported the development of physician incentive
June 6, 2011
Administrator Berwick
Page 2

programs that allow physicians to participate in the sharing of savings generated from quality
improvement efforts.

Moreover, to lower cost and improve quality, payment must be restructured to incentivize integrated
delivery systems that focus on specific patient needs. Furthermore, we encourage collaboration and
accountability among health care providers across treatment settings and sites of care. While we support
the concept of the Shared Savings Program, we believe that incentives should not be based solely on
cost, but should also include increases in value (quality divided by cost). Shared savings can
appropriately align incentives between stakeholders to improve the quality of care for Medicare
beneficiaries leading to reductions in costly complications, the creation of quality guided resource
utilization, and the achievement of sustained savings.

Comments to the Proposed Rule

STS supports the stated goals of the Shared Savings Program, to provide better care to Medicare
patients; to provide better health to populations; and to decrease the cost of health care by reducing
waste in the system. We are also generally supportive of the concept of a properly implemented ACO as
a mechanism to improve quality, delivery, and coordination of patient-centered care for surgical
patients. Unfortunately, the ACO model presented in the proposed rule limits the ability of
cardiothoracic surgeons and other specialists to positively affect those outcomes. In addition, we have
more fundamental concerns about the ability of the ACO concept to encompass the provision of care for
uncommon but resource intensive conditions, such as the management of congenital heart disease,
ventricular assist devices and transplantation for end stage heart or lung failure, and the management of
uncommon thoracic malignancies, without unnecessary duplication of technology and degradation of the
quality of care for these conditions. We briefly summarized our primary areas of concerns above, which
serve as the basis of the following comments:

Section II B. Eligibility and Governance

Comments: First, although STS supports the concept of an appropriately implemented ACO as a
mechanism to improve quality, delivery, and coordination of patient-centered care for surgical treatment
of common conditions, we believe that the proposed rule does not adequately acknowledge and account
for the importance of specialists in the functional model and implementation of ACOs. The success of
an ACO depends not only on the participation of qualified primary care physicians, but also on
specialists, including cardiothoracic surgeons, who will be crucial to the improvement of quality of care.
Additionally, lack of coordination between primary care physicians and specialists can result in
duplication of efforts thereby reducing potential shared savings. As such, for an ACO to be successful, it
will be necessary to promote better coordination with specialists. With regard to the clinical systems
criteria required in the management structure of an ACO, STS supports the use of evidence-based
guidelines developed by appropriate medical specialty organizations that have meaningfully improved

Second, while we appreciate that CMS has clarified that the ACO does not violate the "Prohibition on
Hospital Payments to Physicians to Induce Reduction or Limitation of Services" and therefore does not
June 6, 2011
Administrator Berwick
Page 3

force the participating parties into a violation of the Civil Monetary Penalties provisions, it is unclear
how, under a properly structured ACO, shared savings would flow from participating hospitals to
participating physicians. As the rule clearly states, shared savings should only be distributed by an ACO
(with proper governance and a CMS-approved distribution methodology) to the participating parties
(which include physicians and hospital(s)). We ask that CMS clarify this analysis in the final rule.

Section II E. Quality and Other Reporting Requirements

Comments: CMS proposes to use 65 performance measures in five domains (patient/caregiver
experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly
health) in the first year of the ACO program, with ACOs required to report full and accurate data for
those measures. The vast majority of these measures are harmonized with the Physician Quality
Reporting System (PQRS), the Hospital Inpatient Quality Reporting (IQR) Program, and/or the
Electronic Health Record (EHR) Incentive Program. To the extent practicable, CMS proposes that
measures used be nationally endorsed by a multi-stakeholder organization and aligned with best
practices among other payers and the needs of the end users of the measures. CMS proposes to align the
quality measures specifications for the Shared Savings Program with the measures specifications used in
existing quality programs to the extent possible and appropriate for purposes of the program.

Although CMS acknowledges the need to align the quality measure specifications for the Shared
Savings Program with the measure specifications used in existing quality programs, the 65 proposed
quality metrics do not include quality measures utilized by the STS National Database. As a result,
cardiothoracic surgeons have very little incentive to participate in ACOs because they have diminished
ability to influence the ACO’s savings. This result is problematic for a number of reasons. In particular,
for cardiothoracic surgeons who see improvements in patient outcomes and quality of care resulting
from participation in the STS National Database, those improvements can neither be properly measured
by, nor attributed to any of the measures currently proposed. Thus, STS urges CMS to consider
inclusion of cardiothoracic surgery-related measures in the program. In an effort to align the Shared
Savings Program with the other CMS quality programs, STS recommends that CMS include the
following measures.

Participation in a Systematic Database for Cardiac Surgery
STS supports adding the participation in a systematic database for cardiac surgery as a structural
measure under the list of proposed measures. The measure is currently included in the Hospital Inpatient
Quality Reporting Program. The STS Adult Cardiac Surgery Database (ACSD) is the backbone of the
largest cardiac surgery outcomes and quality improvement program in the world. This 21-year-old
database contains detailed clinical information relevant to the processes and outcomes of care in many
adult cardiac surgical procedures. In addition, the ACSD captures data from 1,032 participant practices
and hospitals, representing almost 3,000 individual surgeons and more than 94 percent of all centers
nationwide that provide adult cardiac surgery. Currently, the ACSD contains more than 4.4 million
surgical records.
June 6, 2011
Administrator Berwick
Page 4

In addition, STS encourages CMS to consider participation in a systematic database for general thoracic
surgery as a structural measure. We believe that adding new registry structural measures is consistent
with the CMS goal not to overburden hospitals with the addition of new measures, and works toward the
reporting of detailed clinical information that can have a meaningful impact on the quality and
efficiency of health care services. Currently, the STS General Thoracic Surgery Database (another of the
three component databases that comprise the STS National Database) captures data from 199 practices
and contains more than 241,436 surgical records. STS is not alone in believing that improved
performance can come only with measurement, and the best methodology for measurement includes
participation in a systematic database.

STS supports adding registry-based measures to the ACO list of quality measures and specifically
endorses cardiac surgery as a measure topic. Data collection using registries not only reduces the
administrative burden for providers, but also ensures that the data are appropriately risk-adjusted and,
therefore, more appropriate and useful for quality improvement and public reporting purposes. STS
supports inclusion of NQF-endorsed cardiac surgery measures and urges that these measures be reported
through a qualified registry.

We envision that providers would submit data to qualified registries, which then would calculate the
measures and submit results, with the numerator, denominator and any exclusions, using a CMS-
specified record layout and file format. STS requests that CMS specify the format for reporting the data
so that it is consistent with the STS infrastructure already in place. Collection, analysis, and feedback to
the local provider/system level of data on quality of care are what should drive the health care system.
The Society’s vast experience with quality measurement in cardiothoracic surgery shows that feedback
to physicians on quality performance may well be the most effective means of changing physician
practice to improve patient care and increase efficiency in provision of care.

STS supports the provision in the proposed rule that requires quality measures have multi-stakeholder
endorsement, and should be developed through a rigorous and stringent process that is transparent,
physician-led, and consensus-based. STS encourages CMS to adopt uniform criteria for qualifying
clinical databases/registries that include these fundamental characteristics, broad representation from a
region or the entire nation, an external auditing process to insure data integrity, a method for risk
adjustment for clinically relevant outcomes, and feedback on risk-adjusted performance to the provider
and/or institutional level.

In regard to the patient/caregiver experience domain, CMS proposes to include measures from the
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinical & Group Survey. In
2010, the CAHPS Consortium adopted the CAHPS Surgical Care Survey. This survey was developed by
the Surgical Quality Alliance to assess patients’ experiences with surgical care, and more specifically, to
encompass the domains of care for the surgical patient that the CAHPS Clinician & Group survey lacks,
including: informed consent, shared decision making, anesthesia care, and post-operative follow-up.
Like the CAHPS Clinician & Group survey, the CAHPS Surgical Care Survey focuses on aspects of
surgical quality that are important to patients and for which patients are the best source of information.
STS recommends that the CAHPS Surgical Care Survey measures be included as a patient/caregiver
experience domain.
June 6, 2011
Administrator Berwick
Page 5

Additional Comments

Section II D. Assignment of Medicare Fee-for-Service Beneficiaries

CMS proposes that primary care physicians upon whom assignment of beneficiaries is dependent would
be committed to the ACO for a three-year period and be exclusive to that ACO. Conversely, specialists
and other entities upon which assignment of beneficiaries is not dependent can participate in more than
one ACO, and thereby facilitate the creation of competing ACOs. These providers and suppliers would
also be required to commit to the three-year agreement to participate in an ACO. This agreement,
however, would not be exclusive, and the specialist would have the flexibility to join another ACO.

Comments: STS supports this proposal to not require specialists to be exclusive to one particular ACO.
We agree that competition in the marketplace and patient access to a variety of providers can promote
better quality of care. Limiting specialists to one ACO, especially in areas of the country where there are
shortages of particular specialists, could encourage the formation of ACOs with undue market power,
which, in turn, could reduce or eliminate the benefits to Medicare beneficiaries of what should have
been the positive influence of market competition.

Finally, STS suggests that CMS specifically consider the problem of uncommon, resource intensive
services that each ACO cannot reasonably be expected to provide without an unsustainable and
economically wasteful duplication of services and which is very likely to result in worse clinical
outcomes for patients due to inability to gain sufficient clinical experience. We also remain concerned
about reliance on payment mechanisms that place provider groups at financial risk for clinical situations
that they have little ability to influence through preventive measures, which can occur in an
unpredictable fashion, and yet require extensive and expensive resources for the best clinical outcomes
to be attained. Although we recognize that ACOs have the potential for increasing the value of care
provided in the healthcare system, we believe that the reimbursement mechanisms must also account for
the types of services that ACOs are unlikely to be able to provide.

STS appreciates the opportunity to provide comments regarding this proposed rule. If you have any
questions about our comments, please contact Phil Bongiorno, STS Director of Government Relations, or (202) 787-1230.


Michael J. Mack, MD

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