"The care part of it is very much focused on innovations in care delivery, inclusive of the diagnostic efforts needed to understand conditions before they become acute, as well as the patient," he says.
In that case, organization is exceedingly important. A legal and management entity must be in place to take on that shared responsibility, with insurance risk being borne by the payer and delivery risk being borne by the caregiver.
At the macro level, there's a tremendous mismatch between the goals of the ACO model and the capacity of the ambulatory services needed to keep a chronic population out of the hospital and on a healthier long-term track.
"There is an insufficient supply of primary care that needs to be hammered away not only with physicians but with advanced nursing and other extended primary care professionals," Enders says.
To help with that transition, the government has included heavy investment in federally qualified health centers through the health reform act, which is a step in the right direction, Enders says. FQHCs are community-based organizations that provide comprehensive primary care and preventive care to underserved and underinsured individuals regardless of their ability to pay.
Some hospitals and health systems, especially safety-net hospitals in urban areas, may not own them but at least have informal arrangements with them so that patients can access follow-up care or even routine checkups. Those relationships will have to change such that the collaboration happens much earlier in the process, and, if hospitals hope to be the center of the ACO, they will have to work to intervene much earlier in patients' lives to cut down on the number of chronic conditions that bring patients to the hospital for acute care. Whether that arrangement can be profitable, however, is another matter entirely.
The same could be said for physician practices.
"We recognize that continuing to align ourselves with physicians by employing them and [having] joint ventures in some clinical areas look like good opportunities, but long-term prospects are unclear," says Gene Diamond, CEO of the Northern Indiana Region at Sisters of Saint Francis Health Services in Mishawaka, IN. "Is there going to be a payoff? The ACO model might really be no better than when it took the form of a managed care bet in the '90s."
With so much uncertainty among the large institutions involved in providing healthcare when it comes to ACOs, where does that put physicians?
Doctors will lead
There are varying opinions about which entity will be the distributor of a bundled payment that could be directed to an ACO. In some cases, it will make the most sense for the hospital or health system to be that entity. In others, it might be organizations affiliated with the hospital but not necessarily the hospital itself. It could conceivably be physician practices or other healthcare providers.