Tom Emerick pushed this out today from his excellent blog (http://crackinghealthcosts.com/index.php/2013/02/aca-inspired-acos-doomed-to-fail/), but it deserves another push. In fact, it deserves as many pushes as it can get. The Accountable Care Organization (ACO) is a critical piece in the projected long-term success of the Affordable Care Act. Like many health care concepts before it, there is more uncertainty about it than there is certainty.
This essay in the Wall Street Journal today does an excellent job of summarizing some of the potential pitfalls, which the ACA’s proponents appear to have glossed over. Unfortunately, the obstacles are so basic and so fundamental, that it’s hard to envision the success of any ACO unless these issues are addressed forthrightly.
I will never forget sitting in a conference room with the senior staff of a huge health system, which will run an ACO, as they bandied about essential issues in managed care, disease management, and wellness. It was sad, and more than a little disconcerting, to watch senior managers who’ve come up through the ranks in the modern managed care era, struggle to define terms such as at-risk, capitation, and risk sharing. The essay authors concentrate on physician behaviors that are deeply ingrained after decades of learning how to live with modern managed care pressures; what of administrators (many of whom are richly compensated and surprisingly illiterate in basic health economics and principles of population health)? They will administer the ACOs and other magic bullets that evolve in the years to come. Upon what history of successful administration of the medical care system will we rest our hopes with them? It is a very precarious ledge, indeed.
Christensen, Flier and Vijayaraghavan:The Coming Failure of Accountable Care – WSJ.com.
The recent opinion piece in the Wall Street Journal by Christensen, Flier and Vijayaraghavan “The Coming Failure of Accountable Care” is excessively pessimistic , factually misleading and surprisingly shallow in its analysis.
I am a family physician in a full-time medical practice for 26 years. For 25 of my 26 years I have managed my hospitalized and nursing home patients. As the practice of primary care medicine has become more challenging I have relinquished these tasks to full-time healthcare teams based at these sites. At my site of service we are now a certified level 3 patient-centered medical home (PCMH). This means we accept the responsibility, among other things, to provide patient-centric, team-based, acute, chronic and wellness care, coordinate care with specialists and hospitalists, and work to engage our patients to get and stay healthier. The redesign of our care delivery system involves every member of my staff and is ongoing.
The first assumption by Christensen et al, “that ACO’s can be successful without major changes in doctors’ behavior” is nobody’s assumption but their own. Primary care doctors across the country are working to become patient centered medical homes. The National Business Coalition on Health (NBCH) representing over 7000 employers and 25 million employees and their dependents is but one of many organizations that have endorsed the PCMH concept and encourage the four pillars of value-based purchasing of health care; standardizing and reporting performance measures, reforming the healthcare delivery payment system and engaging patients in informed decision making. Successful accountable care requires major and daily changes in doctor’s behavior and it is already underway. Witness the recent announcement by the organization “Choosing Wisely” (www.choosingwisely.org). 35 different specialty medical societies representing over 500,000 physicians have identified “five things physicians and patients should question to improve care and eliminate unnecessary tests and procedures”, within their own specialties. This represents a paradigm shift in behavior. These recommendations are incorporated in physician “compacts”, documents governing the principles and practice of medicine. Moreover, this provides liability protection as doctors are more empowered to engage patients in discussions about what tests, treatments and procedures they don’t need and yet they will continue to receive high quality care and often higher quality care.
The second assumption, that ACO’s can succeed without changing patient behavior couldn’t be further from the truth. On the contrary, ACO’s can only succeed with positive patient behavior change. We in healthcare are learning, on the most fundamental level, to ask our patients not “what is the matter with you?” but “what matters to you?” This truly opens the door to meaningful patient engagement. Federal and state governments, employer groups and health insurers are all incentivizing physician groups across the nation to invest time and resources to promote positive patient behavior change. Examples of this include; patient portals that give patients direct electronic access to part or all of their electronic health record, health insurer/medical group outreach coordinators that engage patients at home on site or telephonically to help them better manage their chronic disease(s), employer financial incentives to their employees to encourage periodic wellness visits to their doctor, payment for care coordination to help medicare patients better manage the transition from hospital to home and avoid readmission, widespread physician and staff instruction in techniques of “teachback” and “motivational interviewing” to be sure our patients understand our instructions and to alert us when they are ready to act for positive behavior change.
The third and final assumption contested by Christensen et al is that ACO’s will save money. Well, it’s still too early in the game to know for sure. Christensen acknowledges the potential of the Pioneer ACO’s to save up to $1.1 billion over 5 years. The Pioneer ACO’s 32 healthcare organizations enroll approximately 860,000 medicare patients. Well now there are 330 ACO’s in operation caring for 25-31 million Americans of whom currently 2.4 million are medicare patients. Growth is expected to accelerate in 2013. Do the math. 3X the savings on the medicare side and 10% of the non-medicare population are enrolled. The savings start to add up. Estimates are that 50% of the American population live in areas amenable to ACO care management. Medicare snowbirds notwithstanding, staying connected with patients and healthcare providers wherever they may be keeps getting easier.
Finally, according to the Congressional Budget Office (CBO) 28 million people are expected to obtain individual health insurance under the Affordable Care Act (ACA) not 50 million. Additionally, retail clinics are an excellent venue for managing acute episodic illness in areas where primary care services are limited and for identifying chronic disease in the newly insured who can then be properly referred.
One of the tenets of practicing in a patient centered medical home/ACO is that all providers at every level will practice to the maximum level of their licensure.
The use of mobile healthcare apps and telehealth will be widely deployed in any effective ACO.
The growing empowerment of primary care will help to drive healthcare value. Sound business practices like lean thinking and Six Sigma are already delivering quality and efficiency to the system. We will never eliminate the volume of health care we deliver nor should we. We need to take care of 300+ million Americans. Our goal is to add value.
If successful, ACO’s will deliver exactly the innovation, perhaps disruptive but more important powerful and formative, that our healthcare system so urgently needs.
Thank you for your comment, but you have, either intentionally or inadvertently, completely misquoted the authors. You have erroneously characterized each of the major assumptions in their essay. In fact, that they clearly state that: ACOs CANNOT succeed without changes in provider behavior (paragraph 4); CANNOT succeed without changes in patient behavior (paragraph 6); and, they contest the blanket assumption in the ACA that ACOs will save money (paragraph 10). Just over $1BN in Medicare savings over five years is 0.047% of expected Medicare spending during that period. It is a ridiculously small amount of money saved given the immense hopes invested in ACOs.
Christensen and colleagues are right to urge skepticism by ACO observers, and, if read clearly, thoroughly, and accurately, their essay makes a compelling case for doing so.