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Healthcare Is Local. Why Aren't Accountable Care Benchmarks?

What hurricanes and floods reveal about the shortcomings in value-based care policy.
This post was co-written by Farzad Mostashari, MD, founder of Aledade (headshot)

A little over a year ago, rain started falling in southern Louisiana, and it didn’t let up.

In just a few days in August of 2016, more than 20 inches of rain fell from a storm system. Rivers and waterways like the Amite and Comite Rivers spilled over their banks. Floodwaters submerged more than 100,000 homes and many businesses. Thirteen lives were lost.
 
The flooding was the worst in years—and at the time one of the worst natural disasters in the nation since Hurricane Sandy hit New Jersey and New York. The impact reverberated in schools, homes, and businesses across Louisiana—in many doctor’s offices too.
 
Aledade operates an accountable care organization (ACO) in partnership with independent primary care practices in Louisiana, and many of our partner practices lived through these historic floods firsthand. One even took on water. Fortunately, all of our physicians and their teams were safe.

They were, however, penalized. As members of an ACO in the Medicare Shared Savings Program (MSSP) in their first contract year, Medicare measured the quality and cost of care these practices provided, and compared them to a national benchmark—one that included many practices in communities that didn’t face a once-in-a-millennia flood.

In Louisiana, many of our practices had to close because of the waters. Their patients who needed care either headed straight to a hospital emergency room, or got care at another location, where they had relocated to wait out the floodwaters. And, sure enough, our practices in this ACO experienced their first spike in medical utilization. For 2 quarters, our practices in Louisiana spiked over their benchmark in readmission rates—the only 2 quarters that ever happened.
 
At Aledade, we weren’t surprised. We have argued frequently that CMS should move from a national benchmark for MSSP ACOs to a regional one. The true measure of a successful ACO is whether a patient in Louisiana got better care at a lower cost because their doctor joined an ACO, by comparing their year-over-year cost trends to patients of doctors down the street who didn’t join an ACO. It does no good for Medicare to compare the cost trends for an ACO in southern Louisiana to those in Spokane, Washington—or worse, some strange average of every possible geography across the country. That Louisiana patient can neither seek care in Washington nor from an imaginary “average” hospital.

Today, the move to a regional benchmark has even greater relevance. Communities in Houston and across the state of Florida are recovering from historic flooding caused by Hurricane Harvey and Hurricane Irma. Costs for healthcare providers have already risen for obvious, and tragic reasons. When medications run out, food supplies are disrupted, and power outages affect millions of people, vulnerable seniors suffer. Just recently, 8 people died in a Florida nursing home because of a power outage that knocked out their air conditioning. Emergency room visits and hospitalizations will soar in the aftermath of these disasters in Florida and Texas, but not in Washington. Healthcare providers will find it costlier to care for their patients. But they will still provide care, because promoting the health and well-being of patients is precisely why they took those jobs in the first place.

Today, schools and churches are digging out of mud and sand, and so are a number of doctor’s offices. Chances are, those doctors will also be penalized if they’re in a Medicare ACO—not from malice or bad intentions, but simply from poor program design.



 
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