Will accountable care swallow up primary care?

If you've heard something about "accountable care organizations" (ACOs) in discussions of health care reforms, but you're not quite sure what they are or where they're supposed to fit in, you might find this "Perspective" piece from the New England Journal of Medicine useful. In short compass it defines the term and relates it to the other biggie in health care redesign, the patient-centered medical home (PCMH).

To get the definition out of the way, "an ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population." (Harks back to the day when managed care wore a white hat, doesn't it?) While the PCMH has been much discussed in family medicine over the past five years, at least, the term ACO seems to have emerged only recently.

The NEJM article makes the point that the PCMH and the ACO are, or can and should be, complementary: The PCMH is a model for redesigned primary care, and the ACO is a model for ensuring that the rest of the delivery system works in concert with the PCMH by aligning incentives for the rest of the system with those of primary care.

Sounds neat, doesn't it? The ACO is a way to get referral specialists, hospitals and all the rest to see things our way. Except ...

As the NEJM article puts it, "The fact that the ACO model does not explicitly require support for primary care has led to considerable concern that ACOs dominated by hospitals or specialists would not adequately invest in primary care – or that hospitals and specialists would garner a disproportionate share of any savings." The ACO may be a "provider-led organization," but the providers leading it may well be hospitals, large multispecialty groups or other entities who have not so far proved to be far seeing or even to understand primary care. The NEJM article lists three requirements for successful integration of PCMHs into ACOs:

• Alignment of accreditation and certification criteria for the two organizations: "No ACO accreditation or certification process has yet been developed, but when one is, it will be critical to include criteria that ensure sufficient primary care capacity for the patient population and to closely align the standards with those of PCMH recognition."
• A common set of primary care performance measures: "Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care."
• Wise alignment of incentives: "The payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity."

So all we need to do to achieve a health care delivery system we can be proud of is redesign primary care, redesign the rest of care, avoid the mistakes we've made chronically in past attempts to fix the system, develop system-wide performance measures with a primary care orientation and, oh yes, shift the center of power of the system from secondary and tertiary care to primary care. I hope we're up to the challenge.

Posted at 10:17AM Nov 05, 2009 by Bob Edsall  |  Comments[0]