The growing number of payer-led accountable care organizations (ACOs) continues to remind healthcare industry observers of the rise and fall of the health maintenance organization, but a more nuanced approach to capitation should make the ACOs different, according to the New York Times.
True capitation places the risk primarily on healthcare providers, health economist Austin Frakt wrote. This caused friction, as providers struggled to keep the cost of patient care below the levels set by insurers. Those who survived integrated, consolidated or got out of capitation entirely, Frakt said.
ACOs, on the other hand, paint themselves as partnerships where risk is shared among payers and providers. Coordinated care, quality improvement and information sharing all play a key role.
The recent Empire BlueCross Blue Shield and Mount Sinai Health System announcement demonstrates this. Central to the approach, the organizations said, is the development of a personalized healthcare strategy for patients with complex chronic conditions. These patients cost the most--just 1 percent of patients drive 21 percent of all healthcare spending. If these plans succeed in improving patient health, Mount Sinai will receive "additional compensation."
A similar ACO agreement will give patients of Boulder (Colorado) Community Health access to preventive care, chronic condition and disease management services offered by Humana.
Getting complex care management right is an important part of ACO success, FierceHealthPayer previously reported. Payer-led ACOs will help the healthcare industry achieve the triple aim of reducing costs, improving health care and boosting efficiency, but it will take time.
If there's a downside to the ACO model, the Times said, it's that it does seem to encourage further provider integration and consolidation, as larger provider organizations are better able to negotiate with payers. It's entirely possible these newer, larger providers will negotiate higher prices--which would defeat the entire purpose of healthcare reform.
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