Cardiology Experts Discuss Factors for Success Under the ACO Model

Accountable Care Organizations (ACOs) are designed to improve the quality and continuity of care, but it remains unclear how stakeholders can be successful in this new model and also how the shift in incentives will truly impact care. ACOs are more challenging for specialists, who are focused around a single episode, not around continuity, noted W. Douglas Weaver, MD, vice president and system medical director, Henry Ford Heart and Vascular Institute, Darin Chair of cardiology, Henry Ford Hospital, during his presentation at the Ask the Experts session of the American Heart Association Scientific Sessions, “Achieving Accountability: How Will ACOs Impact the Delivery of Cardiovascular Care?”

In the right type of value-based payment, spending at the primary care physician (PCP) and specialist levels would go up, while hospitalizations would go down. For an ACO to succeed, it must manage cost and quality of specialty care, and redefine the relationship between primary care and specialists, Dr Weaver said. ACOs will need to clearly define the roles for each.

There are inherent risks for specialists, Dr Weaver added. ACOs are a costly and risky way of providing specialized care. The Centers for Disease Control and Prevention estimated the start-up cost for infrastructure alone to be $1.75 million, he said. It could take years to have enough savings to be worthwhile. However, it is still better to participate than to be left out. Dr Weaver told attendees that PCPs will want specialists to develop guidelines and high-value care pathways. “They want everything that is right, but not everything,” he said. Specialists face a potential loss of referrals under this model. Also, Medicare rules say patients can receive care anywhere. Bundled payments may be a better option for the cardiovascular specialist, he stated.

Dr Weaver presented statistics indicating that there are currently 370 ACOs, “with 150 in the wings,” covering approximately 4 million beneficiaries. He presented data from the 32 pioneer ACOs, which achieved a total savings of $87 million ($33 million for Medicare). However, only 13 made money. Twelve pioneer ACOs had significant losses, and 9 exited the program.

In a separate presentation, Karen E. Joynt, MD, MPH, associate physician, Brigham and Women’s Hospital, and instructor in medicine, Harvard Medical School, discussed the potential for ACOs to limit access to care. While the shift away from fee for service is warranted, no one really knows what impact the new incentives will have. The ACO design attempts to better align incentives; however, there is an inherent incentive for ACOs to include only physician networks that serve the healthiest populations. The quality measures include some outcomes-based measures. “You can’t restrict access outside MDs,” said Dr Joynt. “You can’t refer [patients] to lower price providers. You have to lower utilization to save money.” Hopefully, she said, this will lead to reductions in unnecessary rather than necessary procedures and hospitalizations. Under the ACO model, “The most effective way to improve outcomes and reduce cost is to avoid sick patients.”

Dr Joynt also spoke about stakeholder alignment. She said that the fee-for-service model aligned the patient and provider, but this will change under the ACO. Under fee for service, the provider was incentivized to “do more and bill more.” The insurer’s incentives are at odds with this. “The provider and patients kind of fight together against the insurers.” To meet ACO cost targets, the insurance companies and providers are both incentivized to spend less and keep patients out of hospitals. “There is a real risk that patients will be left out in the cold,” she said. The ACO model is new, she said, so there is no evidence as to what will actually occur. “We don’t know if this will happen,” she said. However, she stated that other quality-based programs have shown some evidence of risk aversion. Stakeholders should be aware of the potential for this unintended consequence to occur and should track data going forward with this in mind. “Risk aversion is a real possibility,” Dr Joynt stated.