The promise of Accountable Care Organizations (ACOs), hopefully not as illusive as it appears. Can you manage care without the patient involved?

Centers for Medicare and Medicaid Services (Me...

Better coordination of health care; something I and many others have harped on for years and most recently after first hand experience with the health care system. The Affordable Care Act attempts to address this issue for Medicare by encouraging formation of Accountable Care Organizations (ACO) including providing financial incentives through shared savings. Nobody should argue with such a goal focused on better, more coordinated care. Whether it can work for the Medicare population, whether there can be accurate measures of success and whether health care providers will embrace it to a high degree remains to be seen. The Center for Medicare and Medicaid (CMS) recently made their initial rules more flexible after receiving over 1,000 comments.

However, to be effective doctors, hospitals, long-term care facilities and other providers must form an organization that provides all or most of a Medicare patients (primary) care. The determination of this is made after the fact and since no limitations are placed on patients as to where they receive care it is hard to see how effective this can be. It is like expecting the results of a closed panel HMO from a more traditional health insurance preferred provider organization (PPO). For example, a patient may receive all primary care from the ACO doctor, but expensive surgery and follow-up care from providers not associated with the ACO and yet the ACO would be deemed responsible for coordinating care. It’s managed care for everyone except the patient.

 No doubt the assumption is that providers of primary care will refer all Medicare patients to members of the ACO.  That’s a heck of a lot of coordination. Some large health networks or groups may already be positioned for this effort, but in theory they already are coordinating patient care with positive results.

 Here are some excerpts from the CMS press release

The two initiatives launched today – the Medicare Shared Savings Program and the Advance Payment model – will help providers form Accountable Care Organizations and reflect the significant input provided by stakeholders as well as lessons learned by innovators in care coordination in the private sector.  

 The Medicare Shared Savings Program will provide incentives for participating health care providers who agree to work together and become accountable for coordinating care for patients.  Providers who band together through this model and who meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program.  The higher the quality of care providers deliver, the more shared savings the providers may keep.  

The Advance Payment model will provide additional support to physician-owned and rural providers participating in the Medicare Shared Savings Program who also would benefit from additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems.  The advanced payments would be recovered from any future shared savings achieved by the Accountable Care Organization. 

“As a physician I understand the complexities of caring for a patient who may have multiple providers,” said Donald M. Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services (CMS).  “This opportunity to coordinate care among providers could greatly improve the quality of care Medicare beneficiaries receive.”

Both the Medicare Shared Savings Program and Advance Payment model create incentives for health care providers to work together to treat an individual patient across care settings – including doctors’ offices, hospitals, and long-term care facilities. 

Unlike a managed care plan, Medicare beneficiaries will not be locked into a restricted panel of providers.  Rather, a determination of whether an Accountable Care Organization was responsible for coordinating care for a beneficiary will be based on whether that person received most of their primary care services from the organization.

Ask your doctor what he or she knows about Accountable Care Organizations.

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