Does This ACO Thing Really Mean We Need to be ‘Accountable’?

Last month The American College of Physicians (ACP) released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices.

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

At this time, implementation of the above principles within care coordination agreements represents an aspiration goal…

The care coordination agreements should be viewed solely as a means of specifying a set of expected working procedures agreed upon by the collaborating practices toward the goals of improved communication and care coordination — they are not legally enforceable agreements between the practices. [emphasis of “solely” is in the original document, not added]


Don’t expect to hold us accountable….and don’t expect to be able to sue us if we don’t get it right

Vince Kuraitis, JD, MBA is a health care consultant and primary author of the e-CareManagement blog where this post first appeared.

4 replies »

  1. Bev, you could well be right that bundled payments will result in adoption of Care Coordination Agreements.
    That said, it’s still unfortunate that ACP missed an opportunity for leadership, advancement of patient care, educating members as to impending business realities, and doing the right thing.
    …a few afterthoughts as to antitrust implications here. It’s becoming clear that many are concerned that ACOs could result in concentrating care provider negotiating power, resulting in higher prices.
    The antitrust regulators will ask: is the provider collaboration geared toward enhancing undue bargaining power or toward improving coordination of clinical care.
    To that end, it’s arguably a stronger antitrust defense for ACP and it’s members to say “We absolutely, unqualifiedly recommend that all physicians participate in Care Coordination Agreements because it will improve clinical care.”
    The defense

  2. Although I agree with you that it’s a Freudian slip perhaps related to legal issues, it seems to me that the bundled payment itself will take care of coordination of care issues. Simply put, uncoordinated care costs more and produces inferior incomes, so they should be losing their shirt if the payments are structured properly. Money talks, even in medicine unfortunately.

  3. Dr. M,
    Unfortunately we have to make inferences about how that language got into the ACP position paper.
    You suggest that antrust issues are at play. While that’s possible, collaboration among physicians toward improving clinical integration doesn’t carry a lot of antitrust risk.
    ACP represents both general internal medicine physicians and 13 subspecialties. These groups have differing economic interests. Subspecialists are much more likely to want to preserve the status quo.
    At the very least its odd to read a position paper that’s 99% in favor of Care Coordination Agreements, yet has this caveat clause which essentially says “we don’t really mean it.”

  4. Don’t you think that some lawyer added that verbiage in order to avoid anti-trust litigation and/or to dissuade anybody from the primary care doc up to the cardiologist in the ACO to be sued for that infected in-grown toenail?