Accountable Care Sprints Ahead

A recent report from the Oliver Wyman consulting firm – The ACO Surprise – argues that accountable care organizations are on the verge of triggering a major transformation of the U.S. health system. I hope this prediction comes true.

For all the complexity of ACO regulations (set forth in a 190 page Federal Register document), in my view ACOs make four basic commitments:

  1. Taking responsibility for helping a population be as healthy as possible
  2. Connecting specialties, disciplines, and sites (hospitals, rehabilitation, nursing homes) in a coordinated manner
  3. Engaging patients as active partners – ideally leaders – in promoting their own health and guiding their treatment
  4. Accepting payment for producing valuable results for the population, not on a fee-for-service basis for the individual units of service rendered

Here’s the Oliver Wyman view of the near term ACO landscape:

  • There are 2.4 million current Medicare ACO patients.
  • Medicare ACOs have 15 million non-Medicare patients. The report predicts that they will move towards caring for their 15 million non-Medicare patients in the “ACO manner.”
  • The report predicts that non-Medicare ACOs will care for 8 to 14 million patients.

If Oliver Wyman is correct, it won’t be many years before 10 percent of the U.S. population receives its care in accord with the ACO philosophy. Insofar as ACOs are successful in creating more value for patients per dollar of investment, they’ll come to dominate the marketplace.

With my physician hat on, I see the ACO vision as embodying the fundamental values that motivate most clinicians. The reason I joined the not-for-profit Harvard Community Health Plan practice in 1975 was because it was organized around those values. Many, perhaps most, older physicians whose careers have been in solo or small group practices compensated on a fee-for-service basis are unhappy with the ACO movement, but medical students and young physicians are much more positive about group practice, global payment, and salaried compensation.

With my patient hat on, I’ve chosen to have my own medical care from one of the 32 participants in the Pioneer ACO initiative under the Affordable Care Act. I want my doctors, nurses, and hospitalists (if I come under their wing in the future) to collaborate in what they do with, for, and to me. I don’t want any incentives for overly aggressive treatment to influence their recommendations.

Some years ago a patient of mine was in a severe state of psychiatric crisis. The long-term problem was a major psychiatric ailment, but the immediate challenge was getting control of acute alcohol abuse. I made what felt like a zillion telephone calls (this was before all parties used a shared electronic medical record) to alert all those likely to be involved with my patient to the clinical situation and what I was recommending. A week or so later my patient reported,  with appreciation, “I spoke with nine different people last week and they all said the same thing about alcohol – there must be something to it . . . .” The crisis subsided.

From the perspective of clinicians and patients, care delivered in accord with the first three ACO commitments listed above feels right. The three commitments meet patient wishes and reflect the underlying ideals of the health professions. The fourth commitment is what matters from the economic perspective. I share CMS’s belief that doing the right thing in health care will end up saving money. But that will be a happy result of ACOs, not the reason for going down the ACO path.

James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.






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