Accountable care organizations (ACOs) have befuddled imagers, with radiologists wondering how the specialty might fit into a model seemingly focused on primary care. ACOs have been a hot topic for several years, and generate many unanswered questions. How will the model differ from health maintenance organizations? What methods will they use to cut spending? The answers remain elusive, but with more than 200 ACOs in various stages of operation in the U.S., it’s time for radiologists to take charge of defining imaging’s role in the ACO model.
Primary care has driven most ACO development, which is why many radiology thought leaders suggest the specialty should be aggressive in having its voice heard by ACO leadership. “[Radiologists] need to get out of our departments and start working in operations management. We must establish a strong interdisciplinary clinical presence and start taking positions of greater responsibility in our hospitals and larger organizations as we, by necessity, evolve to become the experts in quality and safety, rather than recipients of blame,” wrote Alexander Norbash, MD, of Boston University School of Medicine, in a Masters of Radiology roundtable discussion published October 2011, in the American Journal of Roentgenology.
Similarly, in a white paper produced by healthcare technology company MedCurrent, Steven Gerst, MD, argued that radiologists should request a seat at the ACO table during contracting and utilization management meetings “rather than have rules and RBMs [radiology benefits managers] imposed upon the ACO’s participating physicians.”
But before they can take an active role in directing an ACO, radiologists need to understand the basics of the ACO model and its growth.
An emerging picture
Mark Smith, MD, MBA, president and CEO of the California Healthcare Foundation, famously said an ACO is like a unicorn: it’s reputed to have mythical powers, but no one has actually seen one. While the jury is still out on the power of ACOs to curb costs, a clearer picture of what the model looks like has emerged.
|03.23.10 Patient Protection and Affordable Care Act (PPACA), which supports the establishment of Medicare ACOs, is signed into law.
11.16.10 Centers for Medicare & Medicaid Services (CMS) launches Medicare and Medicaid Innovation to assess innovative care delivery reforms, including ACOs.
10.20.11 Medicare Shared Savings Program is established as outlined in PPACA.
11.29.11 A total of 164 ACOs are identified in a survey by Leavitt Partners.
12.19.11 The Department of Health and Human Services announces 32 organizations that will participate in Pioneer ACO initiative.
04.11.12 CMS selects first 27 ACOs to participate in Medicare Shared Savings Program.
06.13.12 Leavitt Partners updates research to show a total of 221 ACOs operating in U.S.
07.09.12 CMS adds 89 new ACOs to the Medicare Shared Savings Program, adding that another 400 groups have applied for 2013.
01.01.13 Scheduled deadline for establishment of National Pilot Program on Payment Bundling.
ACOs deliver population-based healthcare, with financial incentives geared toward high-value management of health, rather than pay-per-service or volume-based methods of payment. The Patient Protection and Affordable Care Act (PPACA) included provisions which established a shared savings program for providers serving Medicare beneficiaries. Private payers also can establish ACO collaborations to manage populations enrolled in commercial health plans. ACOs don’t necessarily eliminate fee-for-service, but they provide bonuses to providers who keep costs down. Hospitals and doctors have to meet certain benchmarks, with a heavy emphasis on prevention, and are compensated for keeping patients healthy rather than each service administered.
The primary difference between ACOs and previous cost control models is that providers have more freedom to manage how best to deliver value, and can choose how to divvy up the shared savings reward payments. In the past, cutting costs was about control—preauthorization or conditional payments—while the ACO model is focused on setting targets, providing analytics and offering incentives, then letting healthcare systems determine how to meet their goals, explains Mike Fay, vice president of health networks for Wellmark Blue Cross Blue Shield in Des Moines, Iowa, which has helped create three commercial payer ACOs in the state.