The final rule's changes are unlikely to instigate a flood of new hospital system applicants because the Improvements of the final rule do not change the three fundamental challenges.

First, the final rule does not give most applicants access to capital sufficient to make the investment in care management resources necessary to succeed against the benchmarks.

Second, the final rule does not make it any easier to manage population health without any beneficiary incentives or any closed panel type features.

Third, the final rule does not change the opportunity cost calculus for most applicants. They are likely to expect that their scarce capital and management resources can be invested with a higher likelihood of return in projects that respond to the remaining volume based incentives in the system and which do not have as significant an impact on their volumes.

Most system applicants will also have a preference for a project which ihas a smaller scale and will involve fewer clinical parts in its implementation. Thus bundling will be relatively more attractive than MSSP.

Changes in the final rule for accountable care organizations will improve the chances of getting physicians to participate; but it is not clear physicians are going to flock to ACOs right away.

We are pleased that the government listened to the concerns that were raised about the initial ACO plan. One improvement in the rule was the decision to allow specialists in some cases to act as the primary provider. For example, under the new plan, a patient with advanced heart failure, arrhythmias, congenital heart disease or another unstable cardiac condition that requires management by a cardiologist would not have to get a referral from a primary care physician to see the cardiologist. The specialist could act as the primary care provider while continuing to manage the serious heart condition. This is a sensible approach for the minority of heart patients who need this.

The main ACO acceptability problem is there’s so much uncertainty in the system—especially with the looming threat of 29 percent cuts to physician payments through the flawed formula used to calculate Medicare payments to doctors. The American College of Cardiology has long advocated for a new payment model for health care. We need a system that rewards quality care and better patient outcomes instead of quantity. Medicare has made moves toward rewarding quality, but it’s not enough.

The tools are currently available to support a quality-oriented system in the form of registries established by the ACC and other medical societies. Full clinical registries like the ACC’s National Cardiovascular Data Registry and the PINNACLE outpatient quality program are rich sources of data related to performance measures that give providers and payers the information they need to focus on value—or better outcomes at affordable costs.

Registries attached to EHRs allow physicians to track what’s going on with their patients; they provide an early detection system for problems; and they could provide Medicare with the information needed to create a quality-oriented payment system. Medicare’s database is a claims-based system and does not include the clinical data and guideline-oriented feedback found in medical society registries. Tracking care through clinical registries improves outcomes, reduces readmissions, and helps physicians and patients choose the most appropriate tests to achieve significant savings.