Quality and Cost Targets Not the Only Challenges ACOs Face

February 22, 2012

The biggest roadblock to ACO success may not be difficult cost and performance measures, it may be lack of control providers have over key aspects of participation.

It’s been nearly two months since ACO "pioneers" set out on their journey to improve care quality, reduce care costs, and therefore experience shared savings through a CMS-sponsored program.

Though it’s too soon to tell how successful they will be, Physicians Practice has noted an emerging theme: The biggest roadblock to higher reimbursements may not be difficulty reaching cost and performance measures, it may be lack of control providers have over key aspects of participation.

Patient Problems
Patients within ACOs can see any healthcare provider, even providers outside of the assigned ACO network.

In other words, when Mr. Smith and his wife leave New York each fall to spend the winter in Florida, they could very well be seeing a physician outside of their ACO network for medical care for months at a time.

Anders Gilbert, senior vice president of Government Affairs with the Medical Group Management Association, told Medscape Today this is one of the most “difficult concepts” ACO participants face.

“Once patients go outside of the ACO, so much of what they do or don't do and who they do or don't see lies outside of the individual doctor's control, and yet Medicare will attribute the cost of that care to his or her ACO,” he said. “That's a difficult pill for many doctors to swallow, whether the payer is a private health plan or Medicare.”

Data Downfalls
ACOs receive information from CMS regarding particular patients within their ACO, such as a history of a patient’s medical claims. According to CMS, this provides ACO participants with a more complete view of their patients’ medical needs, and therefore, it makes it more likely the ACO will reach quality and cost targets.

The problem, however, is patients can opt out of sharing their health information with providers. This will make it harder for physicians to reach the quality and cost measures required because they won’t have a benchmark to work from.

Premier Inc., an alliance of large healthcare organizations, refers to this as an “unworkable plan.”

“Without access to beneficiary data, ACOs will be hamstrung in efforts to target interventions that are essential to improve care quality, provide convenient choices and enhance overall compliance with recommended care," the organization said in a statement.

Money Messes
Reimbursements are also another likely problem ACO participants will encounter. There will come a point when they have exhausted all of their options regarding lowering spending and improving care.

Of course, once they hit that breaking point, it will be nearly impossible for them to experience shared savings. A recent Fierce Healthcare article dubs this the “Catch-22” problem.

As we note in a recent Physicians Practice article, ACO participants that are already performing well regarding cost and quality of care may very well struggle the most when it comes to experiencing higher reimbursements.

Robert Berenson, a senior fellow at the Urban Institute told California Healthlinethis is one of the “strange” things about the ACO model.

"If you've been inefficient,” he said, “your potential for getting profits is much higher than if you've been efficient.”