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Part of the healthcare bill is a small section on forming ACOs to curb the rising cost of healthcare spending. For those who are interested in reviewing the bill, click here. In legal terms, an ACO can be found on page 277 under H.R. 3590 - 278, Section 3022 entitled "Medicare Shared Saving Program."
The Center for Medicare and Medicaid Services defines it more simply as the following:
"Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.
The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program."
There are three types of programs of programs to incentivize the healthcare industry to adapt this concept of providing quality care at a cost savings.
- Pioneer ACO Model - a program designed for early adopters of coordinated care. No longer accepting applications.
In addition to the 2% Medicare reimbursement cuts for physicians that started in April of this year, the "Global Payment System," was also proposed where physicians receive a flat fee to manage patients with various diseases in order to reduce the cost of healthcare, has probably incentivized a number of people and organizations to look at the ACO concept more closely.
Organizations and healthcare professionals are not only looking at Medicare patients but all patients in general. In 2012, physicians from nine specialties (representing approximately 375,000 physicians) identified tests or treatments that are over utilized or inappropriate, as part of the "Choosing Wisely" campaign. Led by the American Board of Internal Medicine Foundation (ABIM), in partnership with Consumer Reports, the campaign is trying to educate physicians and patients about care that maybe potentially unnecessary. Examples of these unnecessary tests as reported by FiercePracticeManagement:
- "Screening for osteoporosis with dual energy X-ray absorptiometry in women under 65 and men under 70.
- CT scans or antibiotics for chronic sinusitis.
- Chest X-rays prior to outpatient surgery when the patient has an unremarkable history and physical exam.
- Routine cancer screenings for dialysis patients with short life expectancies or no symptoms of cancer."
Then in February 2013, the ABIM announced another eight medical societies (total of 17 medical societies) have identified 90 more tests and treatments that they claim are overused or inappropriate, bringing the total to 135.
More examples include the following as reported by FiercePracticeManagement:
- "Automatic use of CT scans to evaluate children who visit hospital emergency departments with head injuries: Studies have associated CT scanning with radiation exposure that could significantly increase the risk for cancer. Moreover, researchers recently determined repeat CT scans are unnecessary for patients with mild head trauma if the condition is unchanged or they have improved neurologically."
For the full list of tests, click here.
The "Choosing Wisely" campaign was prompted to get the physician, patient and other healthcare providers to start talking about quality care and where there may be medical tests and procedures that may be unnecessary, or may cause more harm than good. The goal is to disprove the "more is better" mentality for quality care.
The insurance providers have tried to curb cost by stipulating higher co-pays for tests and procedures that are more expensive and lower co-pays for tests and procedures that are less expensive, or what they term value-based insurance design (VBID). Or they will deny coverage for expensive test/procedures unless the physician can prove the merit or necessity of this test.
However, the hypothesis of raising co-pays for tests and procedures that are expensive and lowering co-pays for test and procedures that are less costly, as a means of persuading physicians and patients to lower cost is not that simple and was disproved.
In the JAMA article entitled: Choosing Wisely: Low -Value Services, Utilization, and Patient Cost Sharing, the authors found some interesting results:
1) Several studies have found that patients, who had increased co-pays for their medications, had a decrease in usage and a higher incidence of emergency room visits and hospitalization. These finding seem to imply that decreasing co-payments would correlate with better adherence to patients taking their medications.
2) This prompted studies of decreasing co-pays for high-value medications (less expensive meds or generics) for high risk populations. The results found that lowering co-pays did not result in promoting better compliance with patients taking their medication. Therefore, increasing or decreasing co-pays did not have a mirror image effect.
3) The authors concluded that there were three reasons that could explain the greater effect of increasing co-pays and the lesser effect of lowering co-pays for utilization.
- Patients tend to be loss-adverse and co-payment increases have a greater affect on behavior then co-payment decreases.
- Co-payment reductions every 30 or 90 days maybe too infrequent to motivate daily medication adherence for non-compliant patients or those who can't afford their medication.
- Co-payment increases and decreases target different populations. Co-payment increases target patients who are compliant with medications and co-payment decreases are meant to attract non-compliant patients. But those who are non-compliant will not notice the co-payment decrease because they are not paying for the medication in the first place.
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