What If You Give a Party and No One Comes?

Here is a short update on a post I put up about a month ago about CMS’ proposed regulations for setting up Accountable Care Organizations. The ACO proposal calls for shared savings and other incentives for providers, with a transition after a few years to a real risk contract. But Congress put a “poison pill” into the concept because it was afraid to limit customer choice. At the heart of my argument was this point: “How can you be held accountable, as a provider group, if you cannot control the management of care of your patients?”

The latest news, according to my sources, is that even the most advanced ACO-like organizations like Geisinger and Mayo are not interested in signing on to this proposition. The financial risks can come crashing down quickly and are just too great.

In a recent Boston Globe interview, consultant Marc Bard explains how it would have to work for providers to agree to share risk in an ACO network:

Q. Some consumers fear they won’t be able to go to the doctors or specialists they want in the new system. Is that a legitimate fear?

A. The answer is of course. We can’t be spending 17.5 percent of our gross national product on health care and allow everybody to broker his or her own health care. So ultimately there are going to have to be trade-offs made. The public’s going to have to make them. The delivery systems are going to have to make them. Absolutely there are going to be limitations.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and
front-line driven process improvement at Not Running a Hospital.

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  1. The BCBSMA Alternative Quality Contract (AQC) participants do not seem to have been held back by the attribution of patients without the patients’ knowledge. (For background, see: AQC to ACO: As goes Massachusetts, so goes the nation? (HealthBlawg) http://j.mp/hcv50N.) I suppose that since the AQC is limited to HMO Blue those patients are less mobile (with respect to PCPs), but a patient could easily switch docs mid-year, thereby making the old PCP lose his/her investment in keeping the patient healthy (another version of the problem created by retrospective attribution under the CMS proposed ACO rule). Nevertheless, the providers seem to like the deal. Mayo and Geisinger should, similarly, not experience that much of a patient population shift over the course of a year, given their local market positions. Even if this element of the ACO rule is not changed in the final rule, it seems to me that at least some organizations ought to be very interested in the opportunity presented to become ACOs. Which organizations? The ones that are already building approaches to care that are, or are very much like, the PCMH model. These folks are already spending money on care management, and recognition as an ACO brings with it the opportunity to share in the savings realized as a result of the care management efforts. Finally, the more comprehensive the care management services, the more likely the patient will be satisfied enough to stick with his or her PCP through year-end, thus increasing the odds that the patient will be attributed to the PCP in the ACO.

  2. I knew people didn’t like the language. Hadn’t realized it was bad enough that even Geisinger and Mayo won’t sign on.

    Looks like employers are going to have to take the lead on this, as the politicians aren’t willing to get out in front of the pack and are still trying to be everything to everybody (without actually promising anything that will work).

    The challenge, as always will be adding risk-taking capabilities to provider organizations in a way that can be administered by large employers nationally (ASO subset).

    Since the leading ACO-like players are all regional entities, do you have a sense of who is capable of stepping into the gap?

    Kaiser would seem to have the ability, but it never seems to have the will to make the most of its position. Who else has the balance sheet to absorb risk and the geographic span (with sufficient ability to improve the quality within network health providers) to make any of this happen?

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