ACOs – How does it change the healthcare landscape?

With the adoption of the PPACA and the HITECH Acts as a part of the ARRA in 2009, the stage was set for the rollout and fast implementation of ACOs.  The idea for an ACO was mooted only in 2006 and the very quick adoption and movement towards this model only highlights the importance of reigning in uncontrolled healthcare spending in the US (compare this to the almost 20 year delay in implementation of ICD-10!!!).  So, with ACOs spreading all across the US, what are the possible changes in the healthcare landscape?

What is an ACO?

An ACO is an abbreviation for an Accountable Care Organization, which is a consortium of healthcare entities that form an organization to provide patient centric, co-ordinated care that would benefit the patient and bring down the overall cost of healthcare spending.  The ACO will have a formal structure of Management; will be owned by Physicians who can form the organization through the collaboration of different Providers, Medical Groups, IPAs, Hospitals and Health systems.  The savings that are generated through better co-ordination of care, better utilization management, preventative medicine and better patient management at the Primary care level will be shared in either of two ways (50% flat or 60% with 2% overage) amongst the members of the ACO every year.

Likely Advantages of ACOs

The major advantage is supposed to be for the patient.  The entire healthcare system will now re-align towards better ‘outcomes’ for the patient.  The second largest beneficiaries are the Payers, who can save on unwanted payments that hopefully translate to decreased insurance premiums due to the lesser payouts on claims.  The Providers are benefitted in that they have a set membership base (min. 5000) and fully co-ordinate the care of their patients whether in a Hospital or a Long Term Hospice.  This would reduce the strain on the ERs and Acute Care centers.

Likely Disadvantages of ACOs

The single most fear is that of mis-judging the care level requirement of a patient.  For e.g., a patient that requires hospitalization might not be referred just because the physician has the cost metrics and his savings at the back of his mind.  The level of investments needed to form an ACO is the next big deterrent.  Unless, Provider Groups or IPAs join a Hospital or Health system as part of an ACO, their access to high-end diagnostic and treatment facilities becomes restricted.  The other big fear is that of history repeating itself – the HMOs were formed in the late 70’s exactly for the same reasons and have proven ineffective in controlling costs.

The current scenario

There has been rapid progress in the number of ACOs being formed (from 164 in 2011 to 221 by May, 2012) both for Medicare and for Commercial payers.  Some community based ACOs have also been formed in the last 4-6 months.  There are several questions that are still unanswered – (1) which is the best form of affiliation with the Payer – capitation or FFS (Fee for Service), (2) which is the best savings model to choose (50% or 60%), (3) how best to utilize technology like EMR, e-prescribing and ‘cloud computing’ based Practice Management systems to co-ordinate care with Hospitals and (4) how do you handle the medical claims billing for the Providers in an ACO.

With the Supreme Court’s ruling last week allowing the PPACA and the MSSP rule, the scene has shifted from the Supreme Court to the Presidential campaign.  With the SC ruling touted as a victory for President Obama, the Republicans are sure to target this and Healthcare will be one of the most hotly debated topics during this election campaign.  The fate of ACOs could well hinge on who wins the elections in November.