I recently attended the Society for Healthcare Strategy and Market Development in Chicago. As with many national meetings whose target markets are broad, the current hot topics are easily identifiable by their preponderance and domination of the presentation line-up. This year the winner was Accountable Care Organizations (ACOs).
ACOs have hit the streets with a thunderous bolt following passage of the 2010 Patient Protection and Affordable Care Act. The ACO model is often compared to the gatekeeper model of the 1990’s with one notable exception – the nation’s largest single payer, the government, is asking for it. Like every child knows in school, teachers do not need to say “please” when asking to have the windows closed, lights turned on, or to be quiet. There is no please by the Federal government to develop ACOs; in fact, CMS has shared they are not certain what the specific design, service level, and competencies of ACOs should, will, or are.
One week prior to the SHSMD conference, on 9 September 2010, the Dartmouth Atlas Project released a new study – an analysis of the relationship between Medicare enrollee’s access to primary care physicians and the quality of care received by the consumer. The study’s conclusion was that there was “no strong correlation and widespread variation in access and quality.”[1]
Primary care physicians have lauded the discussion and pending development of ACOs. The medical home model and other initiatives have exemplified the need to elevate the primary care physician from the perceived and financially real dredges of the physician cadre. Citing real improvement in patient outcomes and costs achieved through Independent Delivery Networks (IDN). The four models offered for ACO development include Integrated Delivery Networks, Multi-Specialty Group Practices, Physician-Hospital Organizations, and Independent Practice Associations. The primary care physician is rooted at the base of all of these models.
The design of the ACO requires intensive engagement of primary care physicians to be the focal point of care and thereby ensuring accountability of referral, diagnostic testing, procedural activity, and patient engagement. ACOs have three pillars in their design:
- The ACO is accountable for the entire continuum of care for a defined population of patients.
- Payment reforms reward quality improvement and slow spending increases while avoiding excessive financial risk; the ACO carries the risk.
- Outcome and business analytics measure performance supporting improvement and providing public confidence in the notion that lower cost can be achieved with better care.[2]
The Dartmouth study found:
We found that patients’ access to and use of primary care, and their likelihood of hospitalization, varied markedly in different locations. Although blacks were as little as half as likely to see a primary care clinician and up to 84% more likely to be hospitalized than whites within areas, these racial disparities were less pronounced than the differences across locations.[3]
The shortage of primary care physicians has been a prevailing outcry from medical schools for over a decade. Once the Patient Protection and Affordable Care Act, red flags rose noting the shortage. The referenced study takes this outcry one step farther. Creating a greater supply of primary care physicians will not solve the problem. What the physicians do – care delivery, patient communication, diagnoses, supporting increased patient compliance, and integrating with other providers, nursing, complementary and alternative medicine providers, hospitals.
A second alarming finding is:
Access to a primary care clinician (as measured by having at least one annual visit) by itself is no guarantee that diabetic patients will receive two of the tests they need; nor is the overall amount of office-based primary care delivered in a region, as measured by the number of clinical FTEs per beneficiary (not shown). In other words, having more office-based primary care visits in a region did not automatically translate into higher quality care as reflected in the use of these two diagnostic tests.
There is universal agreement the ability to access primary care is a key factor in preventive care and chronic disease management. All aspects of the current and upcoming industry change points to an increase in patients with chronic disease, incentive to manage those patients in outpatient and ambulatory settings, and reduce total healthcare costs. The Dartmouth study emphasizes the notion that the presence or, access to, primary care alone is not sufficient to garner the improvements in the quality and outcomes desired. It is important to retrain perspective and understand ACOs are one step along a journey. On 16 September 2010, the government reported the number of people without health insurance rose 9.4% to 50.7 million people in 2009, the highest number of uninsured since 1987. This reflects 16.7% of the U.S. population in 2009 compared with 15.4% in 2008. First we need to insure these individuals with access to care; perhaps the learning’s of this study will make that access worthwhile.
[1] “Regional and Racial Variation in Primary Care and the Quality of Care among Medicare Beneficiaries.” The Dartmouth Institute for Health Policy and Clinical Practice, 9 September 2010.
[2] Fisher ES, McClellan MB, Bertko J; et al. Fostering
[3] Regional and Racial Variation in Primary Care and the Quality of Care among Medicare Beneficiaries.” The Dartmouth Institute for Health Policy and Clinical Practice, 9 September 2010.
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