ACOs Widespread, Yet Challenged

Two of the pioneering forces behind accountable care organizations say the model is gaining significance as it proliferates across the country, even though there are concerns over lack of uniformity in performance measures.

While the number of Accountable Care Organizations is increasing dramatically across the United States and showing quality and efficiency successes, many providers are struggling to implement the programs, often due to the wide range of required performance measures.

That was the message delivered this week by Elliot Fisher, MD, MPH, director of The Dartmouth Institute for Health Policy and Clinical Practice, and Mark McClellan, MD, PhD, former administrator of the Centers for Medicare & Medicaid Services, and a commissioner of the Food and Drug Administration. Fisher and McClellan are two of the developers of the ACO model, who spoke at an Accountable Care Organization Summit in Washington D.C. The event focused on payment reform.

Indeed, ACOs are multiplying exponentially, with more than 390 today in every region of the country, working with commercial health plans, Medicaid and states, compared to only about a dozen four years ago, said McClellan, senior fellow of the Brookings Institution and director of the Engelberg Center for Health Care Reform there.

Brookings and Dartmouth have estimated that at least 14% of the American population is now involved in ACO care—about one in seven Americans, McClellan said.

"It's hard to keep up with exactly how large the population is," McClellan said. "The numbers are growing rapidly." They involve hospitals, private insurers, the general population or Medicare beneficiaries.

"The ACO is much more diverse than any one of us expected," Fisher told the D.C. audience, noting there are "a lot of new partnerships, thanks to the kind of energy many of you are bringing to this."

Both McClellan and Fisher noted, however, that many organizations involved in ACO start-ups are trying to overcome challenges in implementing the programs, with concerns especially over lack of uniformity in performance measures sought by the government.

McClellan pointed out that those following the Pioneer ACO Model seek delays and modifications concerning quality metrics, "based on how the measures are calculated, the validity of measures" and, "in some cases, what's the right benchmark to use."

Fisher agreed that some data changes may have to be made. A major concern is variability in performance measures sought by the government in creating ACOs. "There are lots of challenges to ACO implementation. We've been hearing a lot about the need for a common set of performance measures, with everyone agreeing on the same set of measures," Fisher said.

There is a need to align emerging ACO programs with other initiatives, and "the challenge of engaging physicians who are completely stressed out in their current practices, to take the time to engage in a new model of thinking." Fisher noted that the provider side is "struggling to test new models and all of us are trying to learn new ways of practicing in partnerships that are more complicated."

Still, developing ACOs are showing early success in reducing costs, McClellan said. He pointed to ACOs involving Cigna and NovaHealth that have demonstrated dramatic savings in patient care.

Last year, Cigna reported that it was engaged in 16 "collaborative Accountable Care" initiatives in 10 states, involving more than 3,350 physicians, and over 235,000 Cigna customers. Among other things, the report showed that medical costs for 2010 were significantly reduced, $27.04 per patient per month under the ACO, compared with other practices. Performance improvements were also generated, the report said.

As for NovaHealth, an independent physician association based in Portland, ME, Health Affairs reported that in 2011 patients in the program had 50% fewer inpatient hospital stays, 45% fewer hospital admissions and 56% fewer readmissions than unmanaged Medicare populations statewide. Since 2008, NovaHealth doctors participating in Aetna's Medicare Provider Collaboration program have provided care to approximately 750 Aetna Medicare Advantage members.

Early results reflect "new and many variations" in ACOs, McClellan said. "What works best in what circumstances is still very much emerging," he added.

"ACOs are remarkable strategies to improve care, quality and lower cost," Fisher said. "You, on the provider side, are struggling to test new models, and all of us are trying to learn new ways of practicing in partnerships that are more complicated."

Ultimately, "there is so much more opportunity in helping patients learn how to stay healthy and stay out of the emergency room," Fisher said. Providing "great attention to your sick patients gives you the chance to achieve savings," Fisher said. "That's where all the money is," he said.