Along for the Ride?: Surgeon Participation in Accountable Care Organizations

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Accountable care organizations (ACOs) lie at the intersection of policies aimed at capturing health care quality, cost, and value. By managing all of the health care needs for a group of patients, the ACO model offers shared savings to providers in exchange for delivering high-quality care that succeeds in reducing costs.1 The push for ACOs is rooted in the financial forecasts, which predict continued unsustainable growth in health care costs, which will continue to crowd out investment in other vital areas. There are currently 923 active public and private ACOs in the United States (US) providing care for ∼32 million lives or roughly 10% of the population.2 Recently published data by the Centers for Medicare and Medicaid Services (CMS) demonstrated that the 480 ACO groups under its purview were able to achieve $1.3 billion dollars in total cost savings in 2015.3 Further evidence exists that ACOs can improve quality of care, and notably, that physician lead ACOs achieve greater cost savings.4 Nonetheless, the adoption of this new health care model has been incremental and relatively light touch: ACOs decide for themselves where they are going to reduce costs, and participation has been voluntary, albeit with increasing penalties for abstention.
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.
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