Can We Really Trust Accountable Care Organization Models (ACOs)?

  • Can We Really Trust Accountable Care Organization Models (ACOs)?

Can We Really Trust Accountable Care Organization Models (ACOs)?

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Accountable Care Organization models (ACO) are mandated to reform healthcare and to change the way it is delivered. To achieve its goals an ACO has to be cost-conscious and constantly aware about the quality of the care that it delivers. This will result in an organization that is lean with fewer providers caring for many patients. To achieve economies of scale there may be significant consolidation over relatively large areas. These scenarios will make it difficult for independent providers, hospitals, and clinics to operate. As much care as possible will be given in the outpatient setting. There will need to be standardization, automation and rationing.

Automated (and autonomous) medical algorithms can help these ACOs  achieve their goals. Algorithms can be run on the entire population in order to identify high risk members. Algorithms can help patients become engaged in their own care and to maintain a healthy lifestyle. They can enhance a provider’s performance and extend the scope of practice. They can be used to monitor outcomes and to provide early warning of potential problems. Since these can be self-reporting they can improve documentation and demonstrate compliance.

While automated algorithms can help ACOs to meet their goals, in the end whether the ACOs will succeed or not depends on the answers to 4 questions:

  1. What are the real goals of the ACO?
  2. Will the system of payment be more transparent?
  3. Who will advocate for the patient?
  4. Will patients trust the ACO?

Everyone knows that the goal is for the ACO to be accountable for providing quality care. From personal experience many so-called quality measures used by the government are pretty dysfunctional and more about documentation than actually providing any improved outcome. It is assumed that a dictated practice will have the desired outcome so the emphasis is on the metric and not the patient. The “top performing” hospitals often have better information systems and allocate staff to game the system. A cynic may say that the government’s real goal is to save as much money as possible by denying payment for arbitrary reasons.

Probably the biggest problem in healthcare today is the lack of transparency in how it is paid for. Few people on the street realize that what is billed has little to do with what a hospital actually gets paid. Will ACOs be better? Getting paid a flat fee for everyone in a mixed risk pool may be just as opaque. Few people have read all of the Centers for Medicare and Medicaid Services (CMS) documents on ACOs and fewer still can follow how payments will be made. Will the shared savings program evolve into a pay-to-play?

Who is going to be the patient advocate? Providers will be employees and it won’t be in  their job description. A bureaucracy that wants to dodge unhappy customers has many ways at its disposal.  The ACOs will be large enough to have armies of lawyers and large public relations campaigns. The vulnerable patient may find herself or himself all alone. Home care will have benefits to payers other than lower prices, since there are many opportunities for the patient to die unobserved.

In the past there was an incentive to give more care. Now there will be an incentive to provide as little as possible. If I get a flat rate for all members with nothing more for a difficult case, what will keep me from behaving badly? What is the incentive to take care of trainwreck patient if I know that I will get nothing despite my best efforts? If I know Mr. Jones is going to cost me $500,000 for his care, then maybe we don’t need to keep Mr Jones around as long. We surely don’t need all of these expensive ICU beds. Patient trust is easy to lose and difficult to regain.

It appears that ACOs will be an inescapable reality soon. There is a chance that they may work but many opportunities for them to fail. Automation is needed for them to have any chance of success, and algorithms are tools that can be automated. They offer our best hope to provide better patient care and reduce costs.

 


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2015-07-16T20:10:33+00:00

About the Author:

John Svirbely, MD is a founder and Chief Medical Officer of The Medical Algorithms Company and the primary author of its medical algorithms. John is a co-founder of the Medical Algorithms Project and has developed its medical content for nearly 20 years. He has a BA degree from the Johns Hopkins University and his MD from the University of Maryland. He is a board-certified pathologist with a fellowship in medical microbiology and biomedical computing at Ohio State University. Dr. Svirbely recently retired from private practice and resides near Austin, TX. He has authored multiple books and articles on medical algorithms & medical calculators.