This one calls for a big I told you so. Back in 2011 I wrote about Accountable Care Organizations (ACO) and the notion that managing a patients total care and being responsible for that care was nearly impossible when the patient had total freedom to seek care outside of ACO health care providers.
Accountable Care Organizations are a major initiative within Obamacare, especially for Medicare, to manage health care for better quality and cost. However, you can’t manage a patient’s care, if you don’t even know of all the care provided. The study referenced below does not portend well for ACOs that are held accountable for their patients care and its cost.
A study recently published in JAMA Internal Care found the majority of beneficiaries assigned to an accountable care organization went outside of their assigned ACO for specialty care.
Using Medicare claims data from 2010 to 2011 and lists of physicians who participate in ACO programs, the researchers examined the proportion of patients whose assignment to an ACO in 2010 was unchanged in 2011, the proportion of office visits that occurred outside of the ACO and the proportion of Medicare outpatient spending billed by the ACO that was devoted to assigned patients.
The study made the following findings:
80 percent of the beneficiaries assigned to an ACO in 2010 were assigned to the same ACO in 2011.
Beneficiaries with fewer conditions and office visits were more likely to have ACO assignment changes.
9 percent of office visits with primary care physicians were provided outside of beneficiaries’ assigned ACOs.
The number of beneficiaries seeking outpatient specialty care outside of their assigned ACO was greater for higher-cost beneficiaries and occurred often even among specialty-oriented ACOs.
38 percent of Medicare spending on outpatient care billed by ACO physicians was for assigned beneficiaries.
via Study: Majority of Patients Veer Outside of ACO Networks for Specialty Care.
Here are the HHS rules regarding Medicare ACOs. Search this blog for other articles about accountable care organizations.
A beneficiary aligned to an ACO maintains complete freedom to visit any healthcare provider accepting Medicare, just as all Medicare beneficiaries participating in original, fee-for-service Medicare do. These beneficiaries do not need a referral to see a specialist outside the ACO. Unlike a managed care arrangement, like an HMO or a Medicare Advantage plan, a beneficiary aligned to an ACO is free to see any healthcare provider accepting Medicare at any time. In addition, beneficiaries maintain all the benefits to which they are entitled in original, fee-for-service Medicare.
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