WASHINGTON—Accountable care organizations (ACOs) were the topic of much speculation and debate at two recent conferences.
The specifics of ACOs will remain uncertain until the Centers for Medicare and Medicaid Services (CMS) releases rules on the new provider organizations (which were created under health care reform to bring together inpatient and outpatient clinicians to improve quality while reducing cost), but experts offered preliminary perspectives at the annual National Health Policy Conference on Feb. 7 and a seminar at the Brookings Institute on Feb. 1.
Given the uncertainty about what ACOs will be, several speakers focused on what they will not be—a new name for the current silo system, or an HMO, or an incentive to withhold care. “The focus is not withholding care but reducing waste,” said CMS administrator Donald Berwick, MD. “We now invest in volume and throughput. The ACO will invest in value and outcome.”
How value and outcomes will be measured is still uncertain, speakers said. The health care law requires ACOs to be measured in a number of areas, including processes of care, clinical outcomes, patient experience, care coordination, and transitions, said John Pilotte, acting director of CMS's performance-based payment policy staff. The cost of care provided by ACOs will also be measured, and compared to benchmarks based on each organization's past performance. If costs are lower than benchmarks, Medicare will share the savings with the ACO. The ACO will be responsible for distributing the shared savings and collecting and reporting on the quality measures.
Shared savings will provide an incentive for physicians and hospitals to provide the most cost-effective care, possibly reducing demand for expensive technologies, and give more power to primary care physicians to refer patients to the most cooperative specialists, said Hal Luft, PhD, of the Palo Alto Medical Foundation Research Institute. However, some speakers argued that the shared saving system does not go far enough, and the clinicians should also share the risk of losing money if the cost of care exceeds benchmarks.
The ACO model may conflict with anti-trust regulations by establishing financial relationships between clinicians, especially if the clinicians' financial cooperation spread to negotiations with private payers. A cooperative workgroup of the Department of Justice, the Office of the Inspector General and the Federal Trade Commission is currently working on these issues, Dr. Berwick said.
Other issues about ACO implementation still to be resolved include allocation of patients to ACOs (prospective or retrospective), preventing cherry-picking of patients (or the reverse, “dumping” of costly patients), communicating with patients about ACOs, measurement methods of ACO quality, and privacy and data-sharing, the speakers said. Dr. Berwick expressed pleasure with the level of public interest in these issues, and gave a hint that the forthcoming ACO regulations would offer some flexibility. “An ACO won't be one thing. It will be a collection of models,” he said.
ACP issued a policy statement on ACOs in April 2010 and joined the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association in releasing joint principles on ACOs in November 2010.
—Stacey Butterfield, associate editor