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Tuesday Sep 25, 2018

It's Time to Rethink Who Should Be Eligible to Lead ACOs

"Like the sound of a siren song, Oh Carolina, you keep calling me home."
-- Eric Church

[accountable red check in check box]

In the early morning hours of Friday, Sept. 17, a devastating storm hit the coasts of North and South Carolina. During the course of the next several days, nearly 3 feet of rain fell in some areas, forcing thousands from their homes and spreading destruction across both property and public lands. Even as communities begin to rebuild, the threat of flooding continues.

Many AAFP members and their families have been impacted, and the health care delivery system has been disrupted. The AAFP Foundation has launched several initiatives aimed at helping the people, communities, and family physicians Hurricane Florence overwhelmed. I would encourage everyone to consider giving to the AAFP Foundation's Disaster Relief for Hurricanes Fund.(www.aafpfoundation.org) I know your colleagues in the states affected would appreciate your support and generosity as they begin the long, hard work of rebuilding their practices and communities.

Accountable Care Organizations

In August, CMS published a proposed rule titled "Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations -- Pathways to Success."(s3.amazonaws.com) This proposed rule represents the most significant effort to revamp the Medicare Shared Savings Program (MSSP) since its creation as part of the Patient Protection and Affordable Care Act. Currently, there are 561 accountable care organizations (ACOs) participating in the MSSP, providing care to an estimated 10 million Medicare beneficiaries.

In an Aug. 9 Health Affairs blog,(www.healthaffairs.org) CMS Administrator Seema Verma, M.P.H., outlined the administration's vision for how the MSSP should be constructed moving forward. The proposed rule focuses on five goals: accountability, competition, engagement, integrity and quality.

In her post, Verma noted that "the time has come to put real 'accountability' in accountable care organizations." This statement is consistent with others from administration officials who have pointed toward the need to establish greater levels of performance risk in the ACO program as a means of driving value-based payments. As Verma noted in her post, most ACOs participating in the MSSP do not accept downside risk. Of the 561 MSSP ACOs, 460 are participating in Track 1 of the MSSP, meaning they only accept upside risk.

To simplify the program, CMS has proposed collapsing the ACO program into two pathways: basic and enhanced. The basic pathway would allow ACOs to take upside-only risk for two years and then gradually transition to higher levels of risk in years three through five, culminating in year five with a downside risk that meets the advanced alternative payment model risk-eligibility minimum of 8 percent.

So, what makes an ACO successful? The answer is quite simple: physician leadership and a focus on primary care.

Physician leadership appears to be a key attribute of successful ACOs. A recent analysis published in The New England Journal of Medicine(www.nejm.org) makes clear that physician-led ACOs outperform those that are organized around a hospital or health system. The conclusion of the article states, "After three years of the MSSP, participation in shared-savings contracts by physician groups was associated with savings for Medicare that grew over the study period, whereas hospital-integrated ACOs did not produce savings (on average) during the same period."

These findings are consistent with other studies that have demonstrated the ability of physician groups and physician-focused collaborations to deliver higher quality and more efficient care to an attributed population of patients. Although this may come as a shock to many, it really isn't that surprising. Physician-led ACOs are largely composed of primary care physicians who are more connected to patients and more invested in the longitudinal care of those patients.

This brings me to the second key factor, a focus on primary care. We now know that ACOs that place a focus on primary care outperform all other models, hands down. This statement is supported by findings included in the Patient-Centered Primary Care Collaborative (PCPCC) report titled Advanced Primary Care: A Key Contributor to Successful ACOs.(www.pcpcc.org) The PCPCC report's findings can be summarized in two key points:

  • Medicare ACOs with a higher proportion of primary care physicians practicing in patient-centered medical homes (PCMHs) were more likely to generate savings.
  • Medicare ACOs with a higher proportion of primary care physicians practicing in PCMHs demonstrated higher quality scores, including on a significant number of process and outcome measures.

The report concludes by asserting that "a strong foundation of advanced primary care as embodied in the PCMH is critical to the success of care delivery reforms."

From time to time, I find it beneficial to put in writing recommendations that provoke deep thought and a few disagreements. To this end, I would suggest that it is time for CMS to consider prohibiting hospitals and health systems from operating ACOs and require that all ACOs be led by physicians -- preferably, community-based physicians. The growing body of evidence supports this recommendation, as does a simple analysis of the economic factors at play.

Hospitals depend on revenue from occupancy (beds, surgical suites, ER beds, etc.) and utilization of technology. If an ACO is successful, both of those factors should be reduced. Therefore, if your business model depends on occupancy and/or a steady rate of utilization, it is challenging (if not impossible) for you to be truly committed to reducing cost, because cost-reducing actions would reduce revenue.

In short, physician-led ACOs outperform hospital-led ACOs in terms of quality and cost, and they are better positioned to secure cost savings by reducing high-cost services that tend to be associated with hospitals. The cost-saving goals of an ACO are simply incongruent with the economic needs of most hospitals. This is why it's time for CMS to rethink who is eligible to lead an ACO.

Wonk Hard

From time to time, we all need a little reminder to solidify our commitment to a mission, cause or outcome. A reinforcement, if you will, of our individual "why we do what we do." Last week, a person I have never met, University of Texas Southwest Medical Center medical student Jordan Hoese, M.P.H., did just that for me when she tweeted:(twitter.com) "Evaluations that say, 'It is such a disappointment to me that she is going into family medicine' are why I'm going into family medicine. I won't be wasting my potential -- I'm maximizing it!"

I hope that we can do our part to create an environment where she, and thousands like her, can maximize that potential. I'm in. Are you?

Posted at 09:00AM Sep 25, 2018 by Shawn Martin

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.