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-------- Original Message --------
Subject: qotd: ACO patients receive two-thirds of their specialized
care outside of their assigned ACO
Date: Tue, 22 Apr 2014 08:26:50 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>
JAMA Internal Medicine
April 21, 2014
Outpatient Care Patterns and Organizational Accountability in Medicare
By J. Michael McWilliams, MD, PhD; Michael E. Chernew, PhD; Jesse B.
Dalton, MA; Bruce E. Landon, MD, MBA, MSS
In this study of 145 organizations participating in the Medicare ACO
programs, over one-third of beneficiaries attributed to an ACO in 2010
or 2011 was not assigned to the same ACO in both years. Thus, in any
given year, a substantial share of patients for whom an ACO is held
accountable may be newly or transiently assigned. Although healthy
beneficiaries using little primary care contributed to this instability,
unstably assigned beneficiaries were more likely than stably assigned
beneficiaries to be in several high-cost groups that may be targeted for
care management, including the top decile of total spending.
Much of the outpatient specialty care for patients assigned to ACOs,
particularly higher-cost patients with more office visits and chronic
conditions, was provided by specialists outside of patients' assigned
organizations, even among more specialty-oriented ACOs. In contrast,
leakage of office visits with PCPs for ACO-assigned patients was
minimal. In addition, less than 40% of outpatient Medicare spending
billed by ACO physicians was for care provided to beneficiaries assigned
to the billing ACO. This percentage was much lower for
specialty-oriented than for primary care–oriented organizations,
suggesting that ACOs currently provide substantial amounts of specialty
care to patients receiving primary care elsewhere. Thus, at least
initially, incentives in traditional Medicare for organizations
participating in ACO programs may continue to be largely fee-for-service
in nature, particularly for outpatient specialty care.
https://archinte.jamanetwork.com/article.aspx?articleid=1861039
****
Comment by Don McCanne
In this study of Medicare Accountable Care Organizations (ACO), 66.7% of
office visits with specialists were provided outside of the assigned
ACO, especially for higher-cost patients with more office visits and
chronic conditions. That hardly represents a model designed to control
costs.
Some suggest that tighter relationships need to be established between
Medicare patients and ACOs, but that already exists in the Medicare
Advantage plans - a model proven to increase costs. It is clear that the
nebulous ACO concept has only been a wish on the part of policymakers
that physicians and hospitals could somehow organize themselves to
provide better, cheaper care. But we now have enough evidence to state
that ACOs also are a failure.
The vested interests have indicated that they are going to continue to
try to improve the model when it really needs to be replaced. The
direction that they are headed is towards more managed care. What we
need instead is a financing model that is already proven to reduce waste
and improve quality - a single payer national health program. The ACO
advocates need a strong dose of disruption, or they will continue
leading us down the wrong path.
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