Commercial ACOs May Find Footing Where CMS Slips

I am beginning to think that the only people who are truly excited about the eventual release of the final rules and regulation for accountable care organizations are those of us who toil away in the Fourth Estate.

Think about it. When was the last time you heard a hospital, physician or health plan executive say they are waiting for the rules and regs so they can get on with the triple aim focus:  better health for populations, better care for individuals, and lower costs for all?

I remember back in April when Don Berwick, MD, the CMS administrator, introduced the 400+-pages of proposed rules for ACOs. The complex system was roundly booed. Brand names such as the Mayo Clinic and Cleveland Clinic quickly announced that they had no intention in taking part in ACOs. Hospitals and health systems raised concerns about the anti-monopoly provisions, potential problems with data sharing, risk, and the lack of patient accountability. It really seemed like the ACO concept was DOA.

But look what has happened. It seems like almost every day there's another announcement about hospitals, health plans, or physicians creating new delivery systems that hold the promise of care coordination.

"The entire healthcare market is up in the air right now," said William Rupp, M.D. the CEO of Mayo Clinic Jacksonville in Florida. "Everyone is looking at new models of cost-effective care. We're going to see a lot of different delivery models tested and it could be years before we find the models that work."

We're not talking about the government-issue, Medicare-based ACOs touted at every turn by Kathleen Sebelius or Don Berwick. Nope. These new ACOs are centered on commercial health plan membership and they are developing their own rules for meeting quality standards, cutting costs and earning bonus payments or what the Centers for Medicare & Medicaid Services likes to call shared savings.

The commercial ACOs often aren't even called ACOs. They're called alliances, partnerships, affiliations or any number of other names. The Michigan Blues, for instance, calls its program 'organized systems of care.' And these commercial ACOs aren't limited to hospital and physician teams. They are configured to include:

• Health plans and physicians (Anthem Blue Cross and Individual Practice Association Medical Group of Santa Clara County in the San Francisco area or CIGNA and Piedmont Physicians Group in Atlanta)
• Health plans and hospitals (Aetna and Carillion Clinic in Roanoke or Humana and Norton Healthcare in Louisville)
• Physicians and physicians (VISTA Health System and Central Jersey Physician Network in Summit, N.J.)
• Hospital systems and hospital systems (Methodist Health System and Texas Health Resources in Dallas)

Minnesota's Mayo Clinic may not be interested in the CMS version of accountable care organizations, but it is making moves to strengthen and extend its hospital-physician integration model. In May it signed an agreement with Altru Health System in Grand Forks, N.D. Altru's hospital and clinics now have access to Mayo Clinic physicians, as well as to Mayo's disease management protocols, clinical trials, and clinical care guidelines.

While Mayo isn't slapping the ACO name on this arrangement, it certainly reflects efforts to improve care coordination across multiple systems and to provide better care to patients. Time will tell if this arrangement is cost-effective as well.

A few months ago I spoke with Steve Mansfield, president and CEO of Methodist Health System in Dallas.

Methodist Health had just announced its intention to partner with Texas Health Resources on an ACO-like system. The two are by-passing the CMS ACO program.

Mansfield said then that he thought ACOs would be a work in progress for years to come as hospitals, physicians and health plans develop the system that works best for them. "I think the ACO concept is a very valid construct that holds the most promise for us to be able to improve the value of healthcare in America of anything I've seen in my career but it's just a concept. We've got to tweak it until we get the methodology right."

I remember thinking then that Don Berwick should be having sleepless nights over the CMS model for ACOs because all of these stakeholders were going out and forming their own models to achieve the triple aim.

Hey wait a minute. The triple is alive and well! The stakeholders are just pursing it on their own terms. All of the talk about ACOs has really focused healthcare right where Berwick has always wanted it to be: patient centered care coordination.

Does it really matter if it's achieved through a Medicare model or a commercial model?