Former AAFP President Touts Challenges, Opportunities Created by ACOs

When the Future of Family Medicine report was released in 2004, it noted that the delivery model for health care in the United States had to change if family medicine was going to continue to exist. Now, according to former AAFP President Ted Epperly, M.D., of Boise, Idaho, the emergence of accountable care organizations, or ACOs, that are based on the patient-centered medical home, or PCMH, could give family medicine an opportunity to realign the health care system.

Epperly delivered his message during a March 30 Patient Centered Primary Care Collaborative, or PCPCC, stakeholders meeting here that preceded the release of CMS' proposed regulations for ACOs by just one day.

"The Future of Family Medicine report called for two things to change if this specialty was going to be in existence in 15-20 years," said Epperly, who is one of four co-chairs of the PCPCC's newly created Center for Accountable Care. "Number one, the larger health systems need to change, and second, the delivery model of care has to change."

The report has driven the AAFP's focus on making the PCMH the foundation of health care in the United States, and now, as the ACO model is gaining prominence, Epperly noted that the PCMH model has to be the basis for ACOs. Hospitals and other entities within prospective ACOs cannot be allowed to trump medical homes, said Epperly. "We cannot and must not lose primary care as the bedrock for (the health care) system. If we do, we have lost an opportunity."

Epperly acknowledged that there is skepticism in the physician community that ACOs can deliver on the promise of better care for individuals, better health for populations and lower growth in health care expenditures. Many in the primary care trenches may be feeling beaten down by all the changes in the system, said Epperly, but he is gratified to see what has happened during the past three years to change the health care system. "Now we must deliver on that change," he said.

Epperly also called for a realignment of payment for family physicians. "I am a big fan of getting away from fee-for-service -- see one, do one, bill one," he said. A bundled or global payment that captures an episode of care makes more sense, Epperly added.

Family physician David Myers, M.D., director of the Center for Primary Care Prevention and Clinical Partnerships at the Agency for Healthcare Research and Quality, also focused on ACOs during the PCPCC meeting. "Patient-centered medical homes and ACOs are two sides of the same coin," said Myers.

"These are not two different systems that are competing with each other. The patient-centered medical home is the foundation of a rational health care system that strives for better health care, affordable health care and accessible health care."

Elliott Fisher, M.D., M.P.H., director of the Center for Population Health at the Dartmouth Institute for Health Policy and Clinical Practice, also lauded the benefits of the PCMH. "We have seen from the reports already the tremendous success of the model," he noted. "It can have a huge impact on the quality and, presumably, the cost of care."

Like Myers, Fisher said ACOs are going in the same direction as the medical home movement, and he cited a Feb. 1 speech on ACO principles by CMS Administrator Don Berwick, M.D., to back up his claim. In the February speech, Berwick called for continually reducing dependence on hospitals and for keeping patients safely at home -- proof that the CMS administrator does not believe ACOs will be dominated by hospitals, according to Fisher.