ACOs could lead to more robust performance metrics

It's taking longer than we expected for CMS to draw up some more specific ACO regulations. While you wait--don't hold your breath--and take a look at some of the information the Feds are digesting on ACOs, here's just a small sampling of what CMS, OIG and FTC officials heard at a wide-ranging workshop held Oct. 5 on accountable care organizations (the topic at hand was performance measures):

According to Dr. Larry Casalino, who is chief of the division of outcomes and effectiveness research in the Department of Public Health at Weill Cornell Medical College, one thing has not been said enough. To him, one of the best things about the ACO concept is that ACOs should be large enough to have some robust performance measures. While current performance measures are "better than nothing," he said, "they're pretty dinky..."

He added that he hoped performance metrics in the era of ACOs will be more sophisticated than: "Did you order a hemoglobin A1c or not? Check." Payers and enforcement agencies, he noted, should look at things like, not unit cost, but a total cost of care for the population of patients, admissions and readmissions.

Dr. Lee Sacks said that Advocate Physician Partners--a managed care joint venture between the Advocate Health Care system and 3,600 physicians on the medical staffs of Advocate hospitals, which he heads as CEO--uses one set of performance measures for all contracts so that the physicians "aren't schizophrenic." Even in today, where a dominant payer has 70 percent of the commercial market, many specialties don't have enough data on an individual physician or practice to draw any conclusions. "So we have the same measures across 10 commercial contracts and we look forward to having that with Medicare and an ACO, which will make it more robust," he said.

There are consequences if performance measures aren't met, Sacks, who is also EVP/CMO of Advocate Health Care, said. Over time, Advocate created a minimum threshold. If a physician scores below X, not only do you get zero dollars, you're placed on probation, he said. Those doctors who fail to raise their scores the next year, get kicked out of the organization. This year, five physicians left the organization, because "they just didn't get it together" in two years, Sacks said.

Dr. Janet Wright, the American College of Cardiology's senior vice president for Science and Quality, reminded the assembled crowd not to lose sight of the patient as they attempt to improve performance. She told the story of one team at a hospital that was working on speeding up door-to-balloon time--the period of time between the onset of a heart attack and treatment. The team decided the best way to track the time from the onset of chest pain or the patient's arrival at the door to the cath lab was to take a big stopwatch and hang it on a cord around the patient's neck.

The watch would tick during the ER visit and as the patient was whisked down the hall to the cath lab and put on the cath lab table. Everyone was busy watching not the patient's face, but the stopwatch's. At some point, someone realized the patient had asked a question. "What happens when this goes off?" he had asked. - Sandra