ACOs Unable to Overcome Fragmentation

Source: Rich Daly, HFM Senior Writer/Editor. To view the original article click here

Two-thirds of the office-based specialist care provided to accountable care organization (ACO) enrollees was done outside of the comprehensive care entity, a new study found.

The study of 524,246 Medicare beneficiaries assigned to one of 145 Medicare ACOs in 2010 and 2011 also found one-third of the enrollees were switched between ACOs, including “patients in high-cost categories.”

The study, conducted by J. Michael McWilliams, MD, PhD, an associate professor at Harvard Medical School, and colleagues, was published online Monday in JAMA Internal Medicine.

It noted that ACOs, which were created under new testing authority from the Affordable Care Act, aimed to foster greater accountability in the traditional fee-for-service Medicare program by rewarding participating healthcare provider groups that slow spending growth and provide high-quality care.

But among the findings that “could weaken incentives and undermine ACO efforts to manage care” was that 8.7 percent of primary care office visits and 66.7 percent of specialist office visits by ACO enrollees were outside the assigned the ACO.

Among the factors that could undermine ACOs’ ability to meet their goals was that Medicare does not require beneficiaries to pick a primary care physician, the study noted.

In a related commentary, Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change, wrote that the study underscored the importance “of failing to link Medicare beneficiaries with ACOs.”

“By creating a formal and mutually acknowledged relationship between ACOs and beneficiaries, healthcare provider organizations that make the investments needed to coordinate care, manage chronic diseases, and manage population health would be more likely to succeed,” Ginsburg wrote.

Changes Needed

Chas Roades, chief research officer for The Advisory Board Company, said the study showed that the ACO model needs to change.

“Future ACO models should consider structural changes such as prospective patient attribution and the availability of financial incentives at the patient level to encourage beneficiaries to seek care from ACO providers or their partners,” Roades said.

The study followed the January release of ACO performance data that found most of the 114 Medicare ACOs failed to beat their payment targets, and only one-quarter performed well enough to retain a share of the savings they generated.

Meanwhile, the American Hospital Association (AHA) recently urged the Centers for Medicare & Medicaid Services (CMS) to ease ACOs’ ability to earn Medicare bonuses and delay potential penalties, as part of future expansions of the initiative.

Linda Fishman, senior vice president for public policy analysis and development at AHA, wrote CMS that increased hospital participation in ACOs required changes, such as creating more achievable financial thresholds in the early years and allowing beneficiaries to “opt in” to the programs.

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