Physician Alignment Poses Challenge for ACOs

Physician alignment and incentive challenges could prove to be a major hurdle for healthcare providers who want to take part in accountable care organizations.

Richard C. Johnston, MD, an internist with Dallas-based Medical Clinic of North Texas, says hospitals will find ACOs to be a tough sell for skeptical physicians.  "The main stumbling block in physician integration is alignment of incentives. That, and who controls the dollars. Who does CMS write the check to?" Johnston tells HealthLeaders Media. 

 "Since most of the savings in the ACO comes out of limiting hospitalizations and ER visits and readmissions, there is a natural conflict there. If hospitals start to have their reimbursement cuts and if their admissions fall it is going to be difficult to sustain their infrastructure. So, who gets the money and distributes it," he says. "If the hospital is getting the money I would think they would probably try to protect their profitability first and the physicians would be left out there."

A recent survey of 882 hospital administrators and physicians by recruiters AMN Healthcare found that 42% said physician alignment was the most serious obstacle to forming an ACO, followed by a lack of capital (38%), a lack of integrated IT (31%) and a lack of evidence-based treatment protocol data (25%).

David A. Spahlinger, MD, a senior associate dean for clinical affairs at the University of Michigan Medical School, says he's not surprised that physician alignment is becoming a sticking point.

"Yes there are some capital investments you have to make for IT and there are staffing issues, but in the end it's really the alignment of the parts in how we are going to care for patients," he says.

For most healthcare professionals Spahlinger says it's a matter of perspective.

"Physician alignment for health systems is 'how can we make sure the medical staff is on the same page and working together to accomplish system goals?' Every hospital administrator struggles with that," he says. "The physicians say 'Well that is the hospital's goal not our goal. What's in it for us?' That is a major problem in most organizations, and even in the so-called integrated organizations. It's not an easy goal to align everyone in an organization around system goals."

The challenge of aligning disparate groups around a set of unified goals is challenging for any organization, Spahlinger says, and healthcare is no exception.

"With the way they have it laid out in the proposed rules, there are significant hurdles before you see the savings, and it is not clear how much savings you'll get back versus the investment you make," he says. "In order to really accomplish these goals you have to have everybody working on the same page."

Johnston says ACOs should be "driven" by primary care physicians. "And then the primary care group needs to establish relationships with specialists and hospitals and try to get everybody working together to deliver better faster cheaper care," he says. "That is the goal. It is easy to say, but man!"

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