JAMA Article Outlines the Growing Pains of Pioneer ACOs

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An article in the Journal of the American Medical Association outlines what both CMS and the Pioneer ACOs have learned in the early years of the program, such as the importance of engaging primary care physicians, not growing too quickly, and the need to find better ways to count which patients are in the ACO.

Those who followed the fate of the 32 accountable care organizations (ACOs) enrolled in CMS’ Pioneer ACO program have noticed that the ranks have fallen since the launch in 2011. Today, 19 ACOs remain in the nation’s flagship effort to change the reward structure in healthcare from one that rewards volume to one that rewards value.

Today, the Journal of the American Medical Association published an examination of that evolution, going beyond the numbers to the chronicle how the CMS and the ACOs had to adapt on the fly to the lessons learned. As the numbers of Pioneers shrank, the number of Medicare enrollees covered under the program did as well, but quality ratings among the survivors increased, according to authors Hoangmai H. Pham, MD, MPH; Melissa Cohen, JD, MPA; and Patrick H. Conway, MD, MSc.

The Pioneer ACO program is the most ambitious effort to address rising healthcare costs since the managed care efforts of the 1990s, which were criticized for simply shifting risk and limiting access to care in a short-term effort to control costs. Created by the Affordable Care Act, ACOs purport to take the long view by focusing on preventive care and aggressively managing chronic conditions to avoid lengthy hospital stays, rapid readmissions, and high-cost interventions such as organ transplants.

The JAMA paper covers these early efforts, in which ACOs have calculated how they rank in 33 quality measures, many of which focus on diabetes and cardiovascular disease.

One of the biggest challenges has been figuring out which patients belong to the ACO, a process kown as “attribution.” Early on, CMS and the ACOs confront what the authors call “the challenges of managing care of a fee-for-service Medicare population, including the relatively high rate of turnover in claims attributed populations from year to year.” It made little sense for ACOs to invest in care strategies on those patients who would migrate out of the network, and CMS has moved to address this.


“CMS is collaborating with the Pioneer ACOs on a randomized trial of a process for voluntary alignment of patients that would supersede claims attribution based on patients voluntarily attesting that the clinicians they consider their main healthcare professional are in the ACO,” the authors write.

Growing too quickly turns out to be a bad idea, too. The need to engage primary care physicians and their buy-in and cooperation in managing patients is turning out to be a hallmark of success. This finding is consistent with findings of a just-published article in The American Journal of Managed Care, in which a large-scale intervention to trim 30-day readmissions failed to show any difference with usual care. The lead author, Ariel Linden, DrPH, believes the lack of control over the primary care physicians serving the 2 hospitals in the study played a key role, and that this merits further study.

Also, at the recent gathering of AJMC’s ACO and Emerging Healthcare Coalition in Miami, Richard Lubicella, MS, MBA, spoke of the importance of getting primary care physicians on board. “Without primary care engagement, we are simply spinning our wheels,” said Mr Lubicella, who is CEO of Accountable Care Options LLC, a Florida ACO. “The primary care physicians will engage the patients for you if they are engaged.”

Still, the Pioneer ACO program has seen successes. The JAMA article reports a first-year savings of $147 million for 2012, which exceeded projections. Most ACOs outperformed fee-for-service models in 15 areas where comparisons were possible.

Between the first and second years of the program, the number of affected Medicare enrollees dropped from 669,135 to 607,945. However, quality ratings in for health, patient satisfaction and savings all increased. The quality rating of 70.8% for 2012 rose to 84% for 2013. Performance improved in 28 of the 33 quality ratings. And, the amount of shared savings per ACO increased from $87 million to $96 million. Those that succeeded trimmed costs in skilled nursing care and durable medical equipment, as well as Medicare Part A services, which include hospital and hospice care.

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