Surgeons and surgery are missing components in Medicare ACOs

Although surgeons play a large role in caring for patients under accountable care organization (ACO) models, Medicare-approved ACOs haven't paid attention to them, according to a new study in Health Affairs.

Researchers analyzed the experiences of 59 Medicare-approved ACOs using a survey and conducting in-depth interviews with senior leaders at four Pioneer and Medicare Shared Saving Program models. Thirty of the 59 ACOs responded to the survey.

They found that ACOs—which included integrated delivery systems, independent practice associations, multispecialty groups, primary care partners and physician-led organizations--have given little attention to surgical care and instead focus on coordinating care for patients with chronic conditions and reducing hospital readmissions and emergency department visits.

"Surgery was clearly not part of the strategic plans of any of the case study sites," lead author James M. Dupree, a former health policy fellow at the American College of Surgeons who now is a urology surgery fellow for Baylor College of Medicine, wrote. "Tellingly, not a single interviewee could say--or would even guess--how much of their ACO's total expenditures were attributable to surgery."

The broader survey findings also indicated a lack of focus on surgery. Eighty-eight percent said they "didn't know" how much of their total spending was attributable to surgery. And 86 percent rated the goal of reducing unnecessary surgery as very low, low or medium priority. Only 10 percent ranked it high or very high.

Researchers said ACOs will not achieve their desired cost savings and quality improvements by limiting their focus on managing chronic illnesses, readmissions and ED visits. Success may depend on their ability to increase the integration of care--especially managing patients with complex conditions who often require surgical care.

Surgeons, they said, can work directly with primary care doctors to ensure patients receive appropriate but not overly complex preoperative workups. In turn, primary care physicians can work to ensure the chronic conditions associated with poor perioperative outcomes are managed well before surgery. Furthermore, they said surgeons can help patients improve physical function after surgery and reduce readmissions by consulting with home care or rehabilitation facilities to help manage post-perative issues remotely.

"ACO administrators, policy makers, and surgeons need to be aware of these findings, because they have the potential to affect practice patterns and referral streams for surgical patients, the care provided to ACO patients, and the success of ACOs themselves," the study concludes.

To learn more:
- here's the study abstract
- read the study (subscription required)

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