The medical model of "the more you do, the more you make" is out, according to Dr. William Chin, and so is the idea that the physician needs to do everything personally. If a service can be provided more efficiently by a nurse or social worker, that may be the way to go under the next big thing in health care – the accountable care organization.
Dr. Chin, executive medical director for HealthCare Partners, an independent physician association (IPA) based in Torrance, Calif., said his group plans to participate in the new Medicare shared savings program for ACOs, which will launch in January. The group has been preparing for the transition for a while: They are currently also working with Anthem Blue Cross in California to test how an ACO would work in the commercial market as well as testing ACO accreditation standards being developed by the National Committee for Quality Assurance (NCQA).
HealthCare Partners’ physicians in California have been working in the global capitation market for many years and Dr. Chin said this experience will help them transition to being an ACO.
"We have had the experience of improving outcomes and reducing costs, improving patient satisfaction, improving the patient experience in our model," Dr. Chin said. "Some of the common goals of the ACO are things that we are doing today."
This year is likely to be a "learning year" for their practices, Dr. Chin said, as they prepare to meet the various standards being developed for ACOs. One advantage they will have is that their practices have already adopted electronic health records. Without that investment in technology, it’s nearly impossible to become efficient and improve quality because paper charts are intractable to analysis, according to Dr. Chin.
But even with EHRs in place, all practices seeking to become ACOs will have to deal with significant culture changes and shifts in the delivery model, he said.
ACOs have been a hot topic in health care circles since they were written into the Affordable Care Act. The law includes the shared savings program through Medicare, which will allow ACOs to earn additional payments if they can both save the government money and meet quality benchmarks. As the program goes forward, physicians also would assume some financial risk if they are unable to provide cost-effective care.
Officials at the Centers for Medicare and Medicaid Services released a proposed regulation on Mar. 31 outlining how the Medicare ACO program will work. Under the new voluntary program, ACOs could include physicians in group practices, networks of individual practices, hospitals that employ physicians, and partnerships between these entities, as well as other providers. An ACO will be a partnership among both primary care and specialist physicians; however, only primary care providers will be able to form an ACO, according to the proposed regulation.
Providers working in an ACO would continue to receive regular payments under Medicare fee for service, but could qualify for additional payments if they save money for the program. The proposed regulation requires that ACOs meet quality standards and demonstrate that they have reduced costs in order to be eligible to share in savings. The proposal outlines 65 quality measures in five domains: patient experience, care coordination, patient safety, preventive health, and metrics for the care of at-risk and frail elderly populations.
The proposed regulation also creates two models for how an ACO can share in the potential Medicare savings, depending on its level of maturity. Under a one-sided risk model, a less-developed ACO can share in the savings they produce during the first 2 years and then assume financial risk in year 3, sharing in any potential financial losses.
More mature organizations can pursue the two-sided risk model and share in the potential savings and losses immediately. As an incentive to assume risk earlier, ACOs that pursue the two-side risk model will be eligible for a shared savings percentage of 60%, as compared with 50% for those in the one-side risk model.
Physicians’ groups see pluses and minuses in the government’s vision for ACOs.
The proposed regulation has some good points, said Dr. Roland A. Goertz, president of the American Academy of Family Physicians, but doesn’t provide much incentive for small- and medium-size practices to participate. For example, the program focuses on too many quality measures in the first year and the number of covered beneficiaries that must be in an ACO might be too high for many smaller practices to reach. Also, the design for one-sided and two-sided risk is likely too complex to attract practices without experience operating as an ACO, he said.