Along for the Ride?: Surgeon Participation in Accountable Care Organizations
The novelty of ACO payment compared with 1990s capitation is that annual budget targets (and thus the rewards and penalties) are based on a cost trend rather than the total cost of care. This method builds in the potential for cost increases from innovation and sets participants in a race against cost increases in the fee-for-service system. The traditional fee-for-service system reimburses providers based on the volume of services provided such as visits, procedures, lab tests, and consults. This traditional type of payment encourages more services regardless of the actual need or quality with which those services are provided. In the ACO model, fee-for-service payment remains; however, at the end of each year, the total costs of care for an enrolled population are compared with the community fee-for-service trend to determine whether the ACO has been successful and thus eligible for shared savings.
An ideological pivot toward the ACO model brings along with it complexities surrounding integration into an already complex health care system. For the practicing doctor, it looks a little like driving with your feet on the gas and the brakes at the same time. Several interesting questions arise, including which key stakeholders need to be included in the process—the patients, the physicians, the hospitals, or the insurance companies? The paper by Resnick et al5 suggests that to date surgeons involved in ACOs are largely passive participants. The research found that nearly a quarter of surgeons in the United States participate in ACOs. Furthermore, surgeons who were associated with integrated health systems were much more likely to be connected to an ACO than those that practiced independently. Given the heavy focus on primary care in ACOs, these findings suggest that surgeons may be mostly passive participants, though the study does not provide specific information on this point.
Should surgeons be more active participants? We think they should. The field of surgery has a rich tradition of defining, measuring, and critically evaluating outcomes. Through the rigorous study of patient outcomes, the surgical community has also begun to consider what constitutes effective and appropriate patient care, and to focus its knowledge on reducing health care costs while increasing value. The surgical community has the opportunity to take the lead on a rational and evidence-based discourse on how best to demonstrate greater value.