NEJM: ACOs may pose challenge for academic medical centers

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Because of the hierarchical structure of large academic medical centers, they will have difficulty moving toward an accountable care organization (ACO) model, and will need to adopt a more collaborative structure, according to an editorial published Feb. 2 in the New England Journal of Medicine.

Within the editorial, John A. Kastor, MD, of the University of Maryland School of Medicine, Baltimore, asks whether ACOs will be the most appropriate payment model for academic medical centers to continue their efforts on controlling costs while at the same time, delivering quality and coordinated patient care.

Kastor spoke with 37 faculty members and administrators at academic medical centers to gather experiences to better understand the barriers and challenges of these centers adapting to the ACO payment model, which will become part of the Medicare system Jan.1, 2012.

“Establishing ACOs at academic medical centers will be challenging, and creating appropriate governance for these organizations will present problems to many,” Kastor noted. He offered that the “most workable organizational model” would link faculty practice members and university hospitals and clinics in unified management, either legally or virtually.

“However, many academic medical centers are not structured in that way,” noted Kastor. He said that often there is conflict between deans, chairs of clinical departments and directors of hospitals over the utilization and distribution of resources.

“The effectiveness of ACOs will depend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model,” said Kastor. He also said that department chairs may be hesitant to change their traditional methods of operating but without this coordination, academic medical centers will have difficulty reducing costs—a main goal of the ACO model.

Another challenge, said Kastor, is that ACOs require large primary care programs, which large academic centers often don’t have, because specialists, not primary care providers, dominate the academic medical arena. In this case, academic medical centers will need to form partnerships with off-campus primary care groups.

“Leaders at such centers will need to convert their organizations from a hierarchical structure to one that is more horizontal and collaborative.

“Will they be able to do so? Kastor asked. “Given the challenges, several leaders with whom I spoke doubt that ACOs can readily be established at academic medical centers.”