As surprising as it may sound, accountable care organizations do not represent a significant paradigm shift in American healthcare: Instead, they are a compilation of "integration tactics" that have been tried at different times and in different systems, according to a new study from the Deloitte Center for Health Solutions.
Overall, the success of ACOs will depend on how well providers, payers, and patients navigate the "challenges that limited the effectiveness of previous integration and accountability efforts," according to the study, "Accountable Care Organizations: A New Model for Sustainable Innovation."
In the healthcare reform legislation signed last month by President Obama, any pilot ACO program will not take effect until January 2012 and initially will be targeted at Medicare beneficiaries. The exact specifications of an ACO will be left to the discretion of the of the HHS Secretary—using the demonstration project to determine what structures and processes work best and for which region of the country.
A functional ACO should include, however, at a minimum primary care physicians, specialists, and usually a hospital; it also should have the ability to administer payments, set benchmarks, measure performance, and distribute shared savings.
Any group of providers that can administer payments has the potential to become an ACO, according to the report. This includes hospital/medical staff organizations, academic medical centers, and proposed collaborations between health plans and providers.
They can further be divided into: 1) integrated Health systems; 2) multi specialty groups; 3) independent practice associations (also referred to as interdependent physician organizations); and 4) physician hospital organizations.
To move forward, though, four challenges will need to be addressed:
Physician buy in. The American Association of Family Physicians, the American College of Cardiologists, and the American Medical Association have stated their support for payment reform—specifically for ACOs. However, considerable physician opposition is likely to arise if an adequate physician business case cannot be made. In particular, physician groups may resist capitation and penalties that put physicians at risk—which in turn could decrease the ability of an ACO to reduce overall healthcare costs.
Taking lessons learned from physician/hospital organizations, governance issues could surface immediately. In addition, the relationships between primary care providers and specialists have the potential to be an issue. The criteria for physician inclusion or exclusion in the ACO—separate from the issues of credentialing and hospital admitting status—could require considerable thought, according to the study.
Consumer response. Several legislative proposals suggest that patients could be assigned to an ACO based on their primary care physicians. However, patients could be free to see providers outside of their ACOs and could even switch ACOs.
A medical home could serve as an entry point to an ACO. However, unless restrictions are made on provider selection (such as with an HMO), ACOs, payers, and employers may need to capitalize on consumers’ desire for more coordinated healthcare in order to get buy in to the ACO model.
Payments and incentives. No single, agreed upon ACO payment structure exists. The Senate pilot project proposes a voluntary fee-for-service bonus payment—but also adopting capitation if the Senate proposed global payment pilot proves effective.
In the commercial market, health plans may use performance based threshold goals—or milestones—to align payments with provider performance. Health plans would be expected to initiate provider report cards and implement optimal network design—such as open networks versus closed networks or tiered networks—to align provider performance with incentives.
Infrastructure to manage risk. The use of information systems or medical management protocols—plus adherence to state and federal laws—will requires capabilities not usually found within a provider organization. To meet those needs and to manage risk, outsourcing may be necessary.
The "maturation of the ACO model" will necessarily require an "increased willingness to accept substantial risk and effectively manage costs, outcomes and compliance"—all of which should be seamless to patients, efficient for payers and strongly supported by provider, the study noted.
Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.