Who needs to be included in an ACO?

Over the past week or so, it seems the discussion has heated up over who can and should--and has to be--included in the formation of an accountable care organization (ACO). A recent piece in American Medical News, for starters, makes the case that these groups--partnerships that are supposed to improve care and reduce costs across the spectrum of care--needn't necessarily structure themselves around a hospital.

In particular, it cited WellMed Medical Management in San Antonio as an example of a primary-care-physician-led ACO. WellMed, which meets the criteria for an ACO under the Affordable Care Act by serving more than the minimum 5,000 Medicare patients, is made up of 21 primary-care clinics that also have rheumatologists, dermatologists, cardiologists, hospitalists and podiatrists on staff. All other specialty and hospital services are contracted out.

A case study of WellMed's medical-home inspired model showed that the ACO's patients had a lower death rate than those in the same age group in Texas. Subsequent papers are expected to additionally demonstrate notable reductions in the length of hospital stays and the cost of care, amednews reports.

"We feel that physicians can create organizations to manage care and control costs without a hospital," said Gary Piefer, MD, chief medical officer at WellMed Medical Management.

As encouraging as all of this sounds, however, another piece appearing in the Boston Globe this week raises the important question of whether hospital-less ACOs can truly achieve their intended potential.

As the author--a physician whose mother nearly died because of lack of communication between inpatient cardiologists and her regular diabetes doctor--points out, a number of factors in our current health system dissuade physicians, or make it difficult for them to exchange vital information needed for sound medical decision-making. "Due to over-interpreted privacy laws, the lack of compensation for time spent on communication, and disconnected systems, it's difficult and costs us money to communicate with each other," writes Madeleine Biondolillo, MD, corporate medical director of Radius Management Services in Massachusetts.

She continues: "Under the national reform law, 11 months from now, doctors and hospitals will have an opportunity to create accountable care organizations. These connected networks of providers will benefit from, rather than be sanctioned for, communicating and coordinating care. This should save both money and misery, as in the case of my mother's resuscitation [due to an avoidable diabetic emergency sparked by 32 daily oz of apple juice] that shouldn't have been necessary."

While each of these articles demonstrates the important roles of physicians, as well as hospitals, in ACOs, both overlook arguably the most critical entity of all: patients. As a recent commentary in the New England Journal of Medicine points out, it will be difficult for ACOs to achieve their desired savings if patients aren't behooved to get all of their care within the ACO. Pushing patients too hard or in the wrong way to stay inside the ACO, authors Anna D. Sinaiko, PhD, and Meredith B. Rosenthal, PhD, warn, could result in failure similar to the managed-care backlash of the late 1990s. Despite recent Medicare data showing that one quarter of evaluation and management visits and more than one third of hospital admissions took place outside an ACO-like provider group, they point out, there has been little discussion among policymakers as to how to foster patient loyalty to ACOs.

It will remain to be seen what kinds incentives emerge to get patients on board, but they'll likely have something to do with making in-ACO care more attractive to patients' wallets. To more intrinsically sell patients on the benefits of your ACO, consider these strategies outlined in Becker's Hospital Review.

Most importantly, remember the operative word in the term 'accountable care organization.' At the end of the day, patients will make choices. In many cases, they are willing to pay more for better service. Regardless of how they're paying, healthcare consumers value clear and empathetic communication with their providers. Though there is limited evidence that quality data is meaningful to patients, they do expect that clinicians, regardless of their title, are competent to avoid administering a potentially lethal dose of apple juice. Before devoting more time and energy into trying to settle the particulars of an ACO of the future, make sure that the care you help provide today meets these fundamental needs. While this won't guarantee that the rest will just naturally fall into place, it will at least help keep it from falling apart. - Deb