Accountable Care is Accountable to Whom?

By Peggy Salvatore

In the never-ending quest to balance the cost-access-quality triangle, the healthcare system led by the federal government has pursued many variations of payment incentives.

Pay more to get them to do it. Pay less to get them to stop. Only pay after the fact. Only pay before the fact. Only pay for certain incidents and don’t pay for other incidents at all.

The incentive dance continues. Accountable Care Organizations (ACOs) are the latest variation on the theme of incentivized payments with a healthy dose of disincentives thrown in just to scare you. CMS has just drafted rules holding off for three more years a disincentive plan that was scaring providers away from getting on board. To learn more, click here, here and here.

The bloggers, pundits and policy hounds are engaging in betting whether the ACO model has the potential to be viable and effective. Does pay-for-performance really work under the ACO plan? Will disincentives motivate them if the incentives don’t drive them to achieve accountable care?

A Rose by Any Other Name

ACOs, like its predecessor HMOs, and all the bundled and capitated models begat by HMOs, is about capping payment to achieve an outcome. Underneath all the reimbursement formulae is an accountant shifting the risk to providers to get them to control costs and still deliver all necessary care. In some variations of the HMO model, some savings were achieved by some organizations with certain populations and strong prior authorization in place.

There are policy purists who would disagree with my comparison of ACOs and HMOs and all the related sons-of-HMOs. As far as payment incentives and disincentives, ACOs walk much like a duck. What is wholly distinctive about ACOs is that it is a model derived in an environment where the data exists to be much more precise about outcomes and the ability to calculate payments.

That said, ACOs have the potential to achieve their full potential when all the systems are in place to deliver both real-time patient data to treat the patient in front of you and retrospective data to decide if the methods to treat achieved their goals.

Until then, providers who buy into the ACO game are doing it with one eye covered. Most of them understand that they are data-challenged, so they either have opted out of playing or, if they are particpating, about 95% have agreed to partake in the incentives but declined to play the disincentive game just yet.

Accountable to Whom?

The true value in Accountable Care Organizations lies in the premise that ACOs make providers accountable to ensure that patients get the very best outcomes. The value does not lie in providers having to prove to regulators that they have provided adequate care in a way that saved dollars.

When ACOs are focused on the patient to whom they are truly accountable, the cost savings are likely to follow. That will best happen when all the data is available in real time, and trackable retrospectively, to provide high-quality care wherever the point of care may be.