Mayo Clinic recently added its voice to other leading health systems such as Cleveland Clinic, Geisinger Health System and Intermountain Health Care, rejecting ACO participation.  The institutions all felt that the regulations were too restrictive and unduly burdensome. 

Mayo Clinic’s greatest opposition to participation in an ACO hinged on some of the proposed requirements set forth by CMS, particularly that patients be included on oversight boards that judge performance.  Possible antitrust violations raised a secondary hurdle since CMS set limits on the percentage of local populations that can be served within one ACO, and the Clinic already has too high a volume of patients in many of the rural counties .  The health systems, AMA and others also noted the following concerns about the proposed ACO rules:

Financial risk. Many providers had expected the program to offer a way for institutions to get bonuses without having to face penalties.

Quality measures. ACOs will have to collect 65 quality measures, which very few institutions now do. Adding technology and training staff to track this information could be expensive.

Financial solvency requirements. Providers joining an ACO would have to meet financial solvency requirements that could be especially hard for small practices to meet.

Governance requirements. An ACO must be a certified legal entity recognized under state law. While ACO participants must control of three-fourths of the governing body, beneficiaries must be involved in oversight.

Baseline for improvements. The baseline from which providers must improve is set at the current expenses of the provider, which doesn't reward providers who have already lowered their costs.

Member assignment. Since assignment of patients is retrospective, providers won't know for certain which beneficiaries are in their ACO until a year after the program starts.

Start date too early. Many providers believe the start date of Jan. 1, 2012 is set too early. The final rule isn't expected to be released until August, giving ACO-planners four months to meet financial requirements, set up quality metrics and enroll. However, applicants that do not meet the Jan. 1 deadline will be able to apply the following year.