Accountable care organizations are garnering a lot of attention as a way to reform how health care is paid for in the United States, but just about the only thing that experts can agree on right now is that the ACO concept is still in its infancy.
Dr. Steve Allen is the CEO of Nationwide Children’s Hospital, where it has already established itself as a thriving accountable care organization for at least the last five years.
“This is sort of an evolving area of health policy, and it’s not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).
In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs, and that they would share in any savings that were produced as a result. A few models already exist for both pediatric and adult populations.
While many hospitals are still just contemplating their potential role in an ACO, Nationwide Children’s Hospital in Columbus, Ohio, is billing itself as the country’s largest pediatric ACO. It offers one model for how to pursue this concept in the care of children.
Starting about 5 years ago, Nationwide officials partnered with the state of Ohio to assume financial risk in treating children who were covered by the Medicaid managed care program in central and southeast Ohio. To help run the program, they formed a nonprofit physician-hospital organization called Partners for Kids that includes not only Nationwide-employed physicians but also other physicians working in the community.
Under the arrangement, Partners for Kids receives a capitated fee to care for about 285,000 pediatric Medicaid recipients. The organization contracts with three Medicaid managed care plans that retain a percentage of the Medicaid premium to provide claims processing, member relations, and other medical management functions. The hospital and physicians assume the business risk for clinical and financial outcomes.
The idea was to move away from the conventional fee-for-service model while improving access for children who might otherwise have difficulty finding a physician, said Dr. Steve Allen, chief executive officer for Nationwide. For example, Partners for Kids pays primary care physicians in rural areas an increased fee to keep their panels open for these Medicaid patients.
“We saw this as an opportunity to change the paradigm so that we could improve access,” Dr. Allen said.
Officials at Nationwide Children’s Hospital have conducted an analysis of the current ACO landscape and found that about a dozen institutions around the country are planning to develop or have launched some type of a pediatric ACO, with sizes ranging from 30,000 patients to Nationwide’s high of 285,000. Most of the more developed models are among integrated delivery systems, Dr. Allen said.
One integrated system looking to become an ACO is University Hospitals in northeast Ohio, which includes the Rainbow Babies and Children’s Hospital.
Participating in an ACO will mean shifting the system’s focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center and Rainbow Babies and Children’s Hospital.
“Health care in its present design is highly episodic. It doesn’t relate one piece to the other,” he said. Switching to an ACO model “is a transformational change in how care is going to be delivered.”
There has been a lot of buzz around ACOs since the passage of the Affordable Care Act. The massive health reform law includes three sections with implications for forming ACOs. The section that has received the most attention is the Medicare shared-savings program, which will allow groups of providers to work together in treating patients and to share in any potential savings they achieve. That program is set to launch in January 2012. CMS is expected to put out their criteria for the shared-savings program sometime this fall.