Perspective
Perspective Roundtable
Creating Accountable Care Organizations
N Engl J Med 2010; 363:e23October 7, 2010
Comments
open through October 19, 2010
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Under the Affordable Care Act, Medicare will launch a Shared Savings Program for groups of health care providers that join forces, with or without hospitals or health plans, to form legal entities that agree to take responsibility for the quality, cost, and overall care of a population of patients. What will these accountable care organizations (ACOs) look like? Who will step forward to form them? What are the best pathways and likely hurdles to achieving ACO status? What are the risks of entering the arena, and what are the expected benefits for clinicians and patients? In a roundtable discussion moderated by Dr. Thomas Lee, experts Lawrence Casalino, Elliott Fisher, and Gail Wilensky explored these and other questions.
View the video of this roundtable discussion and contribute your comments.
14 Reader's Comments
TODD AUGUST, MD | Physician | Disclosure: NoneHOUSTON TXOctober 13, 2010Just call me old fashioned
As a medical student and a resident in internal medicine I was taught quality care , accountability, and cost containment. Unfortunately with malpractice concerns, third party payments, HMO's, hospital interests, as well as government interventions it has become impossible to practice what I was taught. I hope ACO,s address these issues so medical students can once again practice medicine with compassion and employ the knowledge the are learning today.
CHARLES KNIGHT, MD | Physician - Hospital Medicine | Disclosure: NoneJACKSON WYOctober 12, 2010Bundled Payment/ACO's reforming healthcare? You've got to be kidding!
I assert that Government regulation of the payment side cannot drive reform! The Government must also regulate the punitive medicolegal side, which cannot be left out of the equation! Only by giving care-givers the medicolegal protection to do simply what is medically necessary will reduce costs
So lets be real, bundled payments/ACO's are a threat to physicians. Physicians have no lobbying power, so it would be foolish to think that they would benefit. Furthermore, the Government has already demonstrated that they are not going to pay primary care physicians for their operating costs, much less for what they are actually worth (and they really have no idea of what extensive services that doctors provide that is not on the books--so good luck finding someone else to do it!)
The Gov. will however allow the trial and plaintiff attorneys to continue to rape the system, and deny that such even has an impact. This may all sound like hateful diatribe, but it really is relevant to the discussion in that costs will not be contained with ACO's or any other "reform" because behavior is driven more by the threat of lawsuit than it is by the lack of re-imbursement, for both Providers and Hospitals. And that statement is an inconvenient reality that few are willing to admit. Of course, the people making these decisions cannot visualize what these changes will bring like those fighting in thee trenches. As an example, consider the tidal waves of underpriviledged patients seeking their primary care in the ER (especially in the inner cities); thus medicolegally "declaring an emergency", and thereby triggering a chain reaction of uncontrolled expenses, as the Hospital as well as the "Care-givers" defend themselves.
Good luck trying to ignore the Elephant in the room!CALEB STOWELL | Resident | Disclosure: NoneJAMAICA PLAIN MAOctober 12, 2010Great Discussion
Thank you to the NEJM for hosting this relevant discussion. As a student, I have great hope for a delivery system that rewards value over quantity. But as the discussants pointed out, there is great inertia in the current structure and culture. Much of that culture begins in medical schools and residency programs. I think we need to rethink (or broaden) the business model of medical schools and residency programs. We need more schools and training programs at institutions that are focused on care delivery innovation and not just basic and clinical science innovation. Unfortunately there are relatively few training programs in places like that.
PETER SMITH, MD | Physician | Disclosure: NoneMARSHFIELD WIOctober 11, 2010The usual Specialist Bashing by Health Care Reform
I certainly hope that if one of you has an acute cardiac problem, you do not have to meet a family practitioner in the Emergency Room. I hope that there are Cardiologists that can take care of you and do the appropriate intervention that you might need. One of my colleagues was up all night two nights in a row without any sleep. If you really want to exclude specialists from the discussion, you might get your wish. A plethora of Jack of all Trades, and no one who can take care of the problem.
GIRISHBHAI PATEL, MD | Physician | Disclosure: NoneINGLIS FLOctober 11, 2010How will be measured the quality of care in opacity of privacy ?
A good degree of transparency is required to measure the quality of care in living patient. Information is required to be collected about health of the patient, symptoms of the patient and objective findings followed by actions of the physician and follow up study on outcome. There is a considerable variability with the real meaning of the word used for different symptoms. About Eighty percent of the visits to the physicians are related to psychological problems. It will require a large number of persons to carry out the project. There is already patient's right of privacy. Is it feasible ? Not without speculations and large number of errors and quarrels and chaos !
JULIETA RUIZ ESMENJAUD, MD | Physician | Disclosure: NoneMEXICO DF DEL M HILDAGO MexicoOctober 09, 2010-
Best luck in your efforts to increase the quality of medicine and decrease the expenses....
I do hope something good comes out of all your work.
Sincerely Julieta RuizPAULA MAIONCHI, MD | Physician | Disclosure: NoneRICHMOND KYOctober 09, 2010Quality and sustainability of expanded healthcare
ACO is an interesting idea of qualitly healthcare coupled with reduced expenditures. It will require factors outside of the control of physicians. First your patient population has to 'buy into it' and not go outside the 'care box' without your knowledge. They must control their desire for 'I want it now'. Second hospitals in their constant quest for operating revenue must champion patient care, even when it means NOT doing procedures or tests that make money.
Brining these two aspects together will be challenging, require a culture shift and take time.RANDAL HUNDLEY, MD | Physician | Disclosure: NoneLITTLE ROCK AROctober 08, 2010On Target
This interview is right on target in terms of describing the hopes and the challenges of the ACO. We are desperately in need of a model which makes patient welfare supreme and rewards physicians and hospitals for doing the right things. There is no perfect model, but I hope that the ACO will move us in the right direction.
GUILLERMO GUBBINS, MD | Physician | Disclosure: NoneCORAL GABLES FLOctober 08, 2010Jobless recovery
I am no economist but it seems to me we physicians are in the same quandary as the government and its fiscal deficit in the midddle of a recession. How on earth are we going to improve quality (read create jobs to improve the economy) while cutting costs (read cutting taxes). Sounds contradictory and economically reckless especialy when 18% of the GDP depends on the health sector. It is impossible to do without rationing and ACOs will do exactly that, just like occurred with capitation in the '90s. The only solution is single payer and educating the public to accept that we just can't "have it all for nothing".
MARK PIERCE, MD | Physician | Disclosure: NoneREDDING CAOctober 08, 2010Primary Care Payment Reform
The data has been published. Communities with a higher percentage of Primary Care Physicians enjoy a higher quality of health care at a lower cost. Unfortunately, this value has not been recognized by insurance companies, Medicare, or our patients. Why has the current system failed to evolve?
A less complicated first step would be to increase the financial support of Primary Care Physicians. For years I have been been told to practice evidence based medicine. The data has been published. Why are we waiting?GERALD SITOMER, MD | Physician | Disclosure: NoneBREWSTER MAOctober 07, 2010-
A model of healthcare organization that has achieved higher quality with managed costs is the VA Healthcare System.
EHR makes the facts of evidence based medicine available to physicians, monitors and rewards quality performance, and has controlled costs. Reaching out to communities via local clinics has received popular support from patients and their families.GARY RAFFEL, DO | Physician - Pathology | Disclosure: NoneBETHESDA MDOctober 07, 2010I don't buy it
This is not even close to real world. ACO's are another impediment to the practice of Internal Medicine, creation of more regulation and and indistinct improvement in healthcare for all. I personally am growing weary of how primary care practices can improve their lot by hiring mid level practitioners, who choke the bottom line and do not provide a better overall product. Go to any hospital, and if you do not do your own admissions and in-patient care, a PA or NP will be seeing your patient, dictating post op notes, etc. And then there are the Hospitalists. Another invitation in the grand scheme to marginalize the community doctor. This concept of ACO is simply a continuation of the smoke and mirror approach that our "leaders" continue to impose. Trust me: we are heading down a slippery slope to an abyss which will ultimately reflect the final nail for those of us continuing to practice cost-effective, quality medicine.
SERGIO STONE, MD | Physician | Disclosure: NoneVILLA PARK CAOctober 06, 2010-
Dear Sir/Madam: Are we supposed to believe that all these perspectives, projections, computer models, predictions, estimates and assumptions from your Ph.Ds editorial board are more than voodoo speculations over what is really going to happen with this Health care reform?
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Full Text
What's the alternative?
We are rapidly heading toward spending 20% or GNP on healthcare and if you need a heart transplant or advanced chemotherapy or radiotherapy, AND you have health insurance that you are not likely to lose due to lifetime benefit caps or a link to your job, the system is great now. If you had an MI ten years ago and now have your BP, lipids, weight and sedentary lifestyle are under control and you are totally asymptomatic AND you are similarly insured and are being followed annually or semi-annually be a cardiologist AND a primary care physician and getting your annual stress test, maybe even a coronary calcium score and hsCRP measurement you THINK you are getting good care but you are wasting money.
In a well-designed ACO, your health care dollars are spent only on things that are likely to give you an actual benefit. If you are a 76 year old man with COPD and CHF, you won't get a screening PSA because you will likely die before prostate cancer gets you. If you are an asymptomatic cardiac patient, you won't get a stress test since a positive test is not predictive and a negative test will not tell you anything. If you are a CHF patient, you will have a care manager communicating with you regularly to help you manage your fluid balance and activity and won't have to deal with a physician's office as often. Your doctor will have all your parameters available electronically and will be the head of your disease management team to keep you healthy and out of the hospital.
All the physicians in the ACO will have an agreed-upon method of managing the high volume, high risk problems so there is not major geographic variability in cost and outcomes. Primary care docs won't hand off the care of problems to specialists but will co-manage them. Everyone will do what they need to do and there won't be incentives to do more because if the outcomes are better and the costs are down all participants in the ACO will be rewarded. If costs are down but outcomes are bad, the ACO not only won't do as well financially but might lose the contract to manage those patients.
Or we can just continue to let the insured absorb the cost of the uninsured who come to the ED for preventable problems and spend money on tests and treatments that do not help until all we pay for in the US is health care, social security and defense.