Several of the provisions included within the Affordable Care Act in 2011 designate Accountable Care Organizations (ACOs) as formal, contractual entities.
However, in the real world ACOs come in a variety of shapes and sizes.
When compared to larger, hospital-sponsored ACOs, rural and small physician-led ACOs face a tough challenge, because despite limited resources they need to come up with substantial upfront capital and infrastructure investment to establish a strong ACO foundation.
To help ease this burden, 35 ACOs were selected to participate in the Advanced Payment Model ACO demonstration through a grant program from the Center for Medicare and Medicaid Innovation (CMMI). The grants provided a portion of upfront capital to determine whether or not this financial assistance would help ease the startup burden for smaller ACOs, and increase their success rate.
One of those 35 organizations includes the central Florida-based Physicians Collaborative Trust ACO, LLC (PCT-ACO). They are participants in the January 2013 Medicare Shared Savings Program (MSSP) ACO cohort, along with 106 other ACOs.
Larry Jones, PCT-ACO’s CEO, describes his personal mission as an effort to “preserve and protect the independent practice of medicine.” For over 25 years he has been advocating for physicians through their efforts to organize, negotiate with health plans, and other challenges.
In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).
This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.
We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.
The Current System And Its Drawbacks
State licensure of physicians has been widespread in the United States since the late nineteenth century. Licensure laws were ostensibly enacted to protect the public from medical incompetence and to control the unrestrained entry into the practice of medicine that existed during the Civil War. However, it no longer makes sense to require a separate medical license for each state.
Today, medical standards are evidence-based, and guidelines for medical training are set nationally through the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services’ Graduate Medical Education standards, and the Liaison Committee on Medical Education. All U.S. physicians must pass either the United States Medical Licensure Examinations or the Comprehensive Osteopathic Medical Licensing Examination.
Although the basic standards for initial physician licensure are uniform across states, states impose a patchwork of requirements for acquiring and maintaining licenses. These requirements are varied and burdensome and deter doctors from obtaining the licenses required to practice across state lines.
Since CMS’s Center for Medicare and Medicaid Innovation launched three years ago, its staff have been frequently hailed for undertaking an ambitious research agenda.
But a New York Times story this week was eye-catching for a different reason: author Gina Kolata mostly assailed Medicare’s researchers for how they’re choosing to do that research.
“Experts say the center is now squandering a crucial opportunity,” Kolata wrote in a front-page article. “Many researchers and economists are disturbed that [CMMI] is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research.”
But many researchers and economists that I talked to at this week’s Academy Health conference say that’s not the case at all. (And some were disturbed to learn that they were supposed to be disturbed.)
“RCTs are helpful in answering narrowly tailored questions,” Harvard’s Ashish Jha told me. “Something like—does aspirin reduce 30-day mortality rates for heart attack patients.”
“However, for many interventions, RCTs may be either not feasible or practical.”
“While RCTs may be the gold standard for testing some hypotheses, it is not necessarily the most effective or desirable model for testing all hypotheses,” agrees Piper Su, the Advisory Board’s vice president of health policy.
CMMI’s ambitious goals
On its surface, Kolata’s article is built around a reasonable conclusion: RCTs offer plenty of value in health care, and we’d benefit from more of them.
- As Jha alludes to, think of a double-blinded pharmaceutical study where half the participants randomly get a new drug and the other half get a placebo; that’s an RCT.
- The famous RAND study that found having health insurance changes patients’ behavior: An RCT.
- The ongoing Oregon Health Insurance Experiment: Also, an RCT.
And it’s fair to examine how CMMI is pursuing its research, too.
Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.
I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”
He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.
The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.Continue reading…
One of the few health policy issues that receives bipartisan support is the need to dramatically alter the way providers are paid, shifting from “paying for volume” to “paying for value” to alter the trajectory of health care spending while improving health care quality.
To facilitate this shift, the Affordable Care Act equipped the Centers for Medicare & Medicaid Services with a range of cost-cutting and quality-enhancing tools―the most significant of which might be its new Center for Medicare and Medicaid Innovation. In this blog post, we share insights from recent research funded by the Robert Wood Johnson Foundation on the Innovation Center’s new role, organization, and model selection criteria.
Based on interviews with senior leadership, it’s clear the organization sees its role as two-fold: complementing existing efforts to innovate; and delving into new ideas.
Most of the Innovation Center’s efforts to date have focused on the former―implementing congressionally-mandated demonstrations or ideas that Congress or policy experts have already conceived (e.g., accountable care organizations). More recently, the Innovation Center has begun to seek new ideas from innovators across the country and to promote bottom-up innovation―primarily through its Innovation Challenge.