Health Affairs: ACOs can't fail
 |
“The underlying issue for the country is the value issue: How do we get the best care for Americans at a level of expense that individuals can afford?” Crosson said in an interview, adding that the most immediate problem is that whatever the quality, the cost of healthcare is becoming a problem for public payors and private insurers.
According to Crosson, the concept of accountable care organizations (ACOs) is vitally important for healthcare reform. By engaging physicians and hospitals in re-organizational efforts and different payment structures, physicians and hospitals will begin to see themselves as part of the solution in terms of the cost curve.
Crosson did admit that proposed ACO models still have to jump over a few hurdles. Plus, a fair amount of criticism has surrounded the debate. “However, none should serve to prevent the evolution of this model, because the alternative to a fundamental restructuring of how healthcare is delivered and paid for in the U.S. is likely to be a type of indiscriminate cost cutting that will leave the nation with a damaged healthcare system, reduced access to care services and declining quality of care,” Crosson wrote.
Medicare and commercial ACOs both have inherent issues, according to Crosson. “In the Medicare arena, one of the issues that CMS might not be able to deal with is that the proposed ACO models are built on Medicare Part A and Part B and by statute under Medicare Part A and Part B, beneficiaries have the right to choose their own provider on a point of service basis,” Crosson said. “So if you’re an ACO accepting responsibility for the cost and quality of care but the people you’re responsible for don’t have to receive your care from you, that is a difficult business model.”
In the general ACO arena, Crosson believes the role of hospitals is a significant issue. “If hospitals are going to be part of ACOs, and I believe they should be, and they are going to get paid on a fee-for-service basis based on the number of admissions, then you’ve got an inherent conflict so over time we have to rethink the incentive for hospitals and create a payment model for hospitals which morphs over time for hospitals to manage cost.” An example of this is payors refusing to reimburse hospitals for preventable readmissions within a given time frame; Crosson believes that efforts of this nature should continue to evolve.
Another range of questions around the right payment model exist, posed Crosson. Crosson predicted in the article that the ACO model likely to be successful will be a shared-risk arrangement between payors and ACOs where health plans would take on some financial risk but transfer some to the organization on an ongoing or annual basis. “The reason, simply, is that such shared risk arrangements align incentives between plans and providers, generally leading to cooperative, innovative relationships between them rather than destructive, antagonistic relationships,” wrote Crosson.
The need to succeed is high. “If the whole model fails, it says to payors the delivery system can’t help solve this problem so the payors are forced into a situation where they have no choice but to assume docs and hospitals are part of the problem,” said Crosson.
“The success of the [ACO] concept will require steadiness of political support, especially from Congress and the administration (particularly the Centers for Medicare & Medicaid Services), and eventually public understanding and support,” Crosson wrote in his conclusion. “The success of individual ACOs will require the support of payors, the development of partnership-like behavior between physicians and hospitals, adequate up-front financial resources for nascent ACOs and enough time to allow hospitals and the least-integrated physicians to organize and catch up.”