The 429 page CMS document defining an ACO has finally arrived. How many more trees can CMS kill? The term Accountable Care Organization has been thrown around more times than “paradigm shift,” “tipping point,” and “the greatest thing since sliced bread.” 

It still is lacking in definition. The standardization push can be boiled down to a desire by employers and government to create the so called ACO in the belief that better-organized, standardized care is better care, and that hospitals, physician practices, rehab, surgery centers, diagnostics – you name the healthcare organization – will deliver better care if it is coordinated, and if financial penalties or rewards accrue to those organizations with better outcomes. Will there be a payoff? The ACO model may be no better than when it took the form of managed care and integrated delivery systems in the 90’s. 

I believe one of the best perspectives I have read regarding ACOs was in an article in the March 2011 issue of the New England Journal of Medicine, authored by Robert Kocher, MD, and Nikhil R. Sahni, BS. It was concise and, better yet, it was only two pages. With more than half of practicing physicians (nationally) employed by hospitals or integrated delivery systems, the impact will have long-term repercussions for the practice of medicine.

A recent survey by the Medical Group Management Association (MGMA) shows an increase of nearly 75 percent in the number of active doctors employed by hospitals since 2000. Young doctors tend to value better work-life balance and are more willing than preceding generations to trade higher incomes for the lifestyle and administrative simplicity provided. It is more likely that, under healthcare reform, ACOs were designed for Medicare. (2012, Hospitals, doctors and payers encouraged to join forces in accountable care organizations, Health Care Reform Timeline 2010 – 2020).

In many parts of the country we are already seeing commercial payers looking at ACO models as a concept to reduce their medical loss ratios but the government hasn’t adopted anything past pilot projects (yet). Physicians will have to understand that hospitals are under pressure to implement cost-saving strategies such as standardizing surgical supplies, medical devices, information technology, adherence to clinical guidelines, discharging of patients etc. The penalties to hospitals starting with Medicare, followed by private payers, are going to be re-admissions. 

I want to share with you a discussion from the MGMA's Primary Care Assembly's list regarding primary care leading the way in the improvement and delivery of patient care and eliminating the “silos” of care that exist in the current fractured healthcare system. In this system, evidence-based and patient-centered medicine takes center court. This doesn’t seem like rocket science but let’s look at the change regarding patient discharge.

From this:

• Patient is prepped for discharge
• Patient given discharge instructions by hospitalist
• Patient discharged
• Patient readmitted for same condition within 48 hours because he didn’t understand the discharge instructions.

To this:

• Patient is prepped for discharge
• Patient given discharge instructions by hospitalist
• Patient contacted by Primary Care Physician (or a member of the patient centered medical home team) in 24 hours to see if they understood discharge instructions
• Patient didn’t understand instructions,
• Primary Care Physician sees patient in office immediately.

Studies have shown that up to 74 percent of patients do not understand their discharge instructions leading to readmissions. By changing this one aspect we have made money for the physician while saving money for the system and frustration by the patient. 

Like others, I don’t see the concern of physicians losing their autonomy. Instead, I see more potential to build stronger relationships with specialists and hospitals through the elimination of the silos mentioned previously.

Like it or not, while all the driving forces move us into a very different future, several elements will remind us of those basics that remain constant: (1) financial stability; (2) technological know-how; (3) compensation equity; (4) shared governance; (4) operations expertise; and (5) leadership and human psychology. 

Reference: Integrated Health Care:  Lessons Learned, J. William Appling, Medical Group Management 1999

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