ACOs Ready to Go?

I’ve written about Accountable Care Organizations (ACOs) in previous posts (Accountable Care Organizations and ACO Performance Measures) which will come to fruition next year.  This week, the Health and Human Services Department released the final rules for these organizations.  The regulations are not as burdensome as many feared based on the proposed regulations – ACOs are not required to use Electronic Health Records and only have to meet 33 performance measures instead of the 65 proposed.

To be eligible to become an ACO – a group of providers and suppliers of services must agree to work together with the goal that patients get the right care at the right time in the right setting.  Among other requirements, the final rule states that each group of providers be held accountable for at least 5,000 beneficiaries annually for a period of three years.

All Medicare providers can participate in an Accountable Care Organization to coordinate care, but only physicians in group practice arrangements, networks of individual practitioners, and hospitals that are partnering with or employ eligible physicians, nurse practitioners, physician assistants, and specialists can sponsor an ACO.  The final rule also allows Rural Health Clinics (RHCs) and Federally Qualified Health Centers and critical access hospitals to work together to coordinate care for patients. (See a full comparison of the proposed vs. final rules in this New England Journal of Medicine article.)

The main performance measures remain.  Quality measures are organized into four categories including patient experience, care coordination and patient safety, preventive health, and caring for at-risk populations. It still takes into count communication with your doctor, how many primary care physicians in the organization meet the requirements for meaningful use of electronic health records, reviewing your medications, preventing infections and falls in hospitals, administering scheduled vaccinations, and providing regular health screenings like mammograms and colonoscopies, and monitoring diabetics and those with heart diseases. (for a full list of the performance measures see pages 324-326 of the rules issued by HHS). The performance measures do not require 30-day post discharge physician visits after being hospitalized.  It does not include measures that monitor those with heart failure, COPD, or the frail and elderly.  The measures do not look at microaluminuria, eye exams or foot exams for diabetics.

For the most part, I think these measures are fair and a good starting point to hold doctors and hospitals accountable for good (though not nearly good enough) care.  I do not think they go nearly far enough nor do I think they actually improve patient care.  I think we have allowed ourselves yet again to accept a lower standard of care by not requiring these organizations, and in fact all doctors, to meet the original 65 measures proposed.  While none are perfect indicators of the care provided by doctors and hospitals, they are at least standards to be aspired to.  These measures should be required not as part of a payment plan, but to ensure that patients are actually receiving the best care.

Most disappointing in my opinion is the inclusion of  a measure regarding the patients’ ratings of their doctors.  While doctors should certainly listen to and give consideration their patients’ concerns, requests for treatment, and beliefs, doctors should ultimately be concerned with doing what’s best for the patient.  Doing what’s best for the patient does not always mean doing what the patient wants.  Performing unnecessary tests, prescribing medication a patient may want but may not need, responding to demands for immediate care for conditions that are not emergent and other such patient requests are not always in the best interest of the patient but may reflect in a patient’s satisfaction rating of their doctor.  The problem is, how to measure that a doctor is listening, communicating, and providing adequate access in any other way?  Still, I do not believe that the subjective measure of satisfaction should be one that ACOs are required to meet – particularly when there are so many other measures that have been eliminated.

Will these measures really translate into better care or lower health care costs?  Not likely.  These are measures that as I said all doctors should be held to.  Such standards of care should already be delivered regardless of payment incentives.  Sadly, we are focused on the wrong issue – money.  Actual patient care seems only an after thought.  And by creating payment structures that emphasize cost savings (ACOs), we move farther away from bringing to the forefront the issue that must be addressed – better care.  Only by focusing on the care of the patient – not patient satisfaction scores, blood pressure screenings, and vaccinations – can we make meaningful changes in the health care system.

One last thought.  These measures only look at the Medicare population – those who are over 65.  The measures do not consider the vast majority of individuals who have private insurance or no insurance at all.  How can we be sure that quality care is truly being delivered when the sample is based on one age group?  Many can’t afford care at all, so what will this experimental model mean to them?  Again, the goal should be caring for the patient, the individual.  In truth, the idea of ACOs with a primary focus on payment reform and cost savings does nothing for improving care for the vast majority of Americans.  And without improving care for everyone, we’ll never really bring down health care costs.

So ACOs may be ready to go.  Hospitals and physician groups can take on the rules and regulations and come together to create huge conglomerate organizations that will act in some respects like HMOs in an effort to receive monetary incentives.  They have the blessings of the government including the Federal Trade Commission, Justice Department, and Internal Revenue Service.  They have the support of the American Medical Association and the American Hospital Association (though not the American Health Insurance Plans or American Benefits Council, which represents employers).  But whether ACOs substantially change the way health care is administered and provide better care for all Americans (or even decrease health care costs) remains to be seen.

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See Health.gov’s ACO Fact Sheet

A plethora of interesting views from physicians on patient satisfaction scores from KevinMD.com:

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