What factors must be met to get that ACO classification?
At present, many ACO models are under consideration. However, the consensus view from the member organizations of the AMGA and the legislators identifies several core principles that ACOs should demonstrate.
First, they should be multi-specialty groups. That means they have to have a primary care base, a specialty base and usually, but not necessarily, an affiliation with a hospital system. That association allows the ACO to manage the whole continuum of care for its patients from wellness, to acute care, to chronic care, all the way to high-end tertiary care.
Second, these ACO systems should be physician-led, because it’s how the physicians perform, the types of decisions they make, and the governing structure for how the ACO manages physician performance that has to drive the quality outcomes ACOs are seeking.
Third, the ACO must be willing to be held accountable for clinical results and cost efficiencies for the populations they are serving.
Fourth, the ACO should have a culture of commitment to continuous learning and improvement. This should be achieved through the gathering and use of data to improve the efficiency and safety of patient care.
Fifth, ACO incentives must be aligned to foster voluntary participation. Delivery systems should participate because they believe at the end of the day it enhances quality of care and lowers cost trends as opposed to participating out of a sense of coercion.
You can not just create an organization of physicians through contractual relationships and achieve the outcomes described. What makes these systems function well is the culture that is created around physician governance, accountability and metrics that determine the quality outcomes. That is the cultural piece that has to overlay on integration of the entities of the delivery system.
Why is there more focus on reforming the ‘payor’ instead of the delivery system?
The approximately 47 million people who have been documented as uninsured hurt the whole system, because when these patients show up in the emergency room without coverage, they usually have a more complicated form of their illness. Therefore, they generate more expense. Usually, their inability to pay out of pocket leads to cost shifting: those who have insurance see their premiums increase.
The focus on payors is to lower premiums, to change the underwriting principles and get everybody into the game. But if you do everything the same once they are in system, you just make short-term expenses worse.
You have to change the way the delivery system functions to produce higher quality and lower costs. One of the keys to lowering the cost of care over a period of time is achieving genuine, measurable, quality improvement. Wellness and prevention are the first step in quality.
What are the difficulties and challenges of making the ACO model mainstream?
It will be hard to implement these systems in rural areas because the populations are small and dispersed. Also, just because you put these entities together under a contract and call it an ACO doesn’t mean it will work. You have to get physicians on the same page when they are used to a system that rewarded them for how much they did and didn’t hold them accountable for the outcomes of the populations they managed. That will be a new concept, so it could be slow to develop.
Ronald Copeland, M.D., is president and executive medical director of the Ohio Permanente Medical Group.
