ACP: How accountable care is a team sport

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

ACP: How accountable care is a team sportOn March 31, 2011, CMS issued a proposed rule to implement a section of the Patient Protection and Affordable Care Act (ACA) that requires the HHS Secretary to establish a Medicare Shared Savings Program. Under the proposed rule, eligible providers and hospitals that create or join accountable care organizations (ACOs) can continue to receive traditional Medicare fee-for-service payments under Medicare parts A and B and be eligible for additional payments based upon satisfying quality and cost savings requirements.

The governance of each ACO will have authority for its clinical operations, including establishing processes that promote patient engagement, evidence-based medicine, care coordination, and quality and cost measure reporting.

ACO adoption

Following the CMS release of the proposed rule, the CMS Center for Medicare and Medicaid Innovation (CMMI) announced several new ACO initiatives, including a “Pioneer ACO Model,” intended to accelerate adoption of ACOs. The Pioneer Model is “designed for health care organizations and providers that are experienced in coordinating care for patients across care settings.”

However, most newly formed ACOs will not initially have in place processes to provide and manage the continuum of complex care across differing institutional settings, including ambulatory and inpatient hospital – and will need to develop them.

Care coordination and the PCMH model

Part of the challenge for ACOs in managing the continuum of care is the complexity of patient care networks, particularly for patients with chronic disease. For example, in a 2009 Annals of Internal Medicine article, Hoangmai Pham and colleagues surveyed more than 2,200 primary care physicians who participated in the Community Tracking Study, demonstrating that a typical primary care physician in a Medicare practice coordinates care with nearly 230 other physicians in about 120 other practices.

As ACOs form, how then will clinical processes be established so that all eligible providers in the ACO coordinate care and collectively make good decisions for patients and the ACO, while promoting evidence-based medicine? Are there frameworks or models for care coordination to assist new ACOs already in place? One promising model is the Patient Centered Medical Home (PCMH), a model specifically designed to improve care coordination and which may be foundational for ACOs.

Using the PCMH model, Group Health of Puget Sound (a staff model HMO), reported success two years into a pilot study in improving patients’ care experiences, quality, and clinician satisfaction, while reducing health care costs.

PCMH neighborhood

While the PCMH may be foundational for an ACO, it will not be sufficient to meet the care coordination requirements involving specialists, subspecialists and other clinicians, particularly where eligible providers and hospitals have previously functioned as independent entities under fee for service models. Recognizing that care coordination extends beyond the medical home to the medical “neighborhood”, the American College of Physicians (ACP) and its Council of Subspecialty Societies (CSS), developed a 2010 position paper on the relationship between the medical home and medical neighborhood (PCMH-N). While the PCMH-N position paper was developed for internal medicine specialty and subspecialty practice, the principles (below) may apply to all disciplines.

Key recommendations of the ACP PCMH-Neighbor position paper:

  1. Recognition of the importance of collaboration of specialty and subspecialty practices to achieve the goal of improved care integration and coordination within the PCMH care delivery model.
  2. Definition of a PCMH-Neighbor as it pertains to specialty and subspecialty practices. The PCMH-N should:
  • Ensure effective communication, coordination, and integration with PCMH practices in a bidirectional manner to provide high-quality and efficient care
  • Ensure appropriate and timely consultations and referrals that complement the aims of the PCMH practice
  • Ensure the efficient, appropriate, and effective flow of necessary patient and care information
  • Effectively guide determination of responsibility in co-management situations
  • Support patient-centered care, enhanced care access, and high levels of care quality and safety
  • Support the PCMH practice as the provider of whole-person primary care to the patient and as having overall responsibility for ensuring the coordination and integration of the care provided by all involved physicians and other health care professionals.

The development and successful implementation of an ACO should be rewarding for patients and the eligible providers caring for them, providing both patient and professional satisfaction, and financial reward through shared savings.

There are existing examples of accountable organizations, such as staff model HMOs and vertically integrated health systems, where complex care has been successfully provided and coordinated along the continuum of care across differing institutional settings. For newly forming ACOs developing required clinical processes, models such as the PCMH and PCMH-N may provide a framework to coordinate complex patient care.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • drdarrellwhite

    Very nice, comprehensive review. Thanks.

    How will ACO’s, whether medical homes or neighborhoods, integrate the care of the specialist or sub-specialist whose care is truly episodic, especially if the highest quality outcomes and greatest efficiency possible exists in a free-standing specialty clinic?

  • pcp

    Those who use the Group Health experiment as a model of what we should aspire to, need to look at the fine print:

    1. Compared to the controls (other Group Health clinics), the patients involved were in better health at baseline, better educated, and whiter

    2. Each physician in the study had his patient panel cut by a full 25% with no reduction in salary (one can assume the hundreds of patients who lost their docs were not included in the satisfaction surveys!)

    3. Support administrative and clinical staff was increased by up to 75%

    4. Results: doctor satisfaction up (duh), medical costs per patient reduced by a statistically insignificant 2% (it’s hard to tell from the studies, but that seems to be a reduction in CPT codes, so it doesn’t look like the tremendous increase in overhead was factored in, but don’t quote me on that).

  • Innovadoc

    There is a better way without getting mixed up in all this mess-

    Just kick the insurers out of the exam room:

  • buzzkillersmith

    It is an axiom of business that one should not invest in what one does not understand. What will ACOs do to your revenue? Your costs? Your hassle factor? Your quality of care? I for one have no idea.

    • Marc Gorayeb, MD

      Agreed. Think about the incentives to get specialists, surgeons, etc.. to join what is essentially a super-HMO. My guess is that the most successful, skilled and talented people will have little incentive to join in on such an opaque business model. Those likely to join: well, you can fill in the blanks.

  • John Ryan

    The future of the patient & physician in the ACO model is very predictably dismal, based on government and insurer behavior in so many previous initiatives. After the first 2 years of enhanced reinbursement, the ACO model introduces “risk-sharing” — the ACO will share increased costs by receiving lower reimbursements. The “real” managers of the ACO, the insurers and the federal regulators, will turn the screws on the weakest partners, physicians & patients, reducing pay & benefits respectively. There may even be a return to economic profiling and physician disincentives, justified (of course) by care protocols developed administratively with the ACO, and heavily influenced by the administrative sector of the ACO, with the bottom line in mind.

    What we all should remember, and Dr. Tooker and the rest of the ACP leadership doesn’t seem to realize, is that the true purpose of ACOs is to reduce cost. Faced with a growing older population, increasing demands for services and medical technology, it is a mistake to allow corporate medical entities, government and insurers so much influence, while denying physicians and patients the right to organize in their own interests.

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