A study, “Outpatient Care Patterns and Organizational Accountability in Medicare,” published April 21 in the Journal of the American Medical Association (JAMA) Internal Medicine, examined patient care patterns in Accountable Care Organizations (ACOs). The authors examined three construct measurements: stability of assignment, defined as the proportion of patients whose assignment to an ACO in 2010 was unchanged in 2011; leakage of outpatient care, defined as the proportion of office visits for an assigned population that occurred outside of the contracting organization; and contract penetration, defined as the proportion of Medicare outpatient spending billed by an ACO that was devoted to assigned patients.
The authors found that of beneficiaries assigned to an ACO in 2010, 80.4 percent were assigned to the same ACO in 2011. Of those assigned to an ACO in 2010 or 2011, 66 percent were consistently assigned in both years. What the authors called “unstable assignment” was more common among beneficiaries with fewer conditions and office visits but also among those in several high-cost categories. Among ACO-assigned beneficiaries, 8.7 percent of office visits with primary care physicians were provided outside of the assigned ACO, and 66.7 percent of office visits with specialists were provided outside of the assigned ACO. Leakage of outpatient specialty care was greater for higher-cost beneficiaries and substantial even among specialty oriented ACOs. Of Medicare spending on outpatient care billed by ACO physicians, 37.9 percent was devoted to assigned beneficiaries. This proportion was higher for ACOs with greater primary care orientation.
The authors concluded that care patterns among beneficiaries served by ACOs suggest distinct challenges in achieving organizational accountability. Continued monitoring of these patterns may be necessary to determine the regulatory need for enhancing ACOs’ incentives and their ability to improve care efficiency.
In a related commentary, Paul B. Ginsburg, PhD, University of Southern California, Los Angeles, said, “There is broad consensus among physicians, hospital and health insurance leaders, and policymakers to reform payment to healthcare providers so as to reduce the role of fee for service, which encourages high volume, and instead to use systems that reward better patient outcomes, such as bundled payments for a population or for an episode of care.”
He also said that the Affordable Care Act accelerated this movement by defining ACOs, specifying how ACOs are to be paid, and how they are to relate to beneficiaries. Further, he said, by not offering incentives to beneficiaries to choose an ACO or to commit to their healthcare providers, the potential of this approach to improve care and control costs has been hindered, as confirmed by the study referenced above.