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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Accountable Care Organizations: Accountable for What?

Dr Robert Potenza and Dominica Potenza, partners in life and in work, are, respectively, a cardiologist and a registered nurse who have a cardiology/internal medicine practice in the Bronx. (Dominica, who is pursuing a Doctorate of Nursing Practice at Hunter College, City University of New York, to become a nurse practitioner, is a student of mine.) Bob still makes hospital visits to his patients when they are admitted to nearby Montefiore Medical Center, instead of having them managed by Montefiore’s hospitalists.

Diana Mason, PhD, RN

The Potenzas’ visits with patients are rarely brief because they take time to understand their patients’ illnesses in the context of their lives. For example, the patient with diabetes is not just diabetic; he’s a man who lives in a neighborhood without a place to exercise safely. Seen in this light, continuity of care is much more than merely making sure a patient is discharged with the right medications.

In theory, continuity of care should be improving at Montefiore, one of 32 Pioneer Accountable Care Organizations (ACOs) that aim to become models for improving population health while lowering costs. Montefiore has been acquiring physicians’ practices to expand its primary care capacity, but the Potenzas are reluctant to join, fearing they’ll lose what control they have over the personalized care they give their patients.

“Continuity of care is increasingly being lost because many physicians who know their patients well are not being adequately reimbursed, so they don’t accept [hospital] admissions on their own patients,” Dominica told me. “These patients are then taken care of by hospitalists. The hospitalists, while well intentioned, do not comprehensively know the changing medical problems of these patients. We know our patients, and that can make a critical difference in care.”

Why ACOs?

In a recent United Hospital Fund report on ACOs in New York State, Gregory Burke defines accountable care as

a contract between an organized group of providers and a payer, under which the providers agree to be held accountable for providing the full range of health care services required by a defined cohort of that payer’s members. In return, the payer agrees to allow participating providers to share in any savings they are able to generate as a result of providing high-quality, efficient care to that population.

Why do we need ACOs?

For one thing, we do a poor job of managing patients with chronic illnesses. In the 10 years between 1999-2000 and 2009-2010,  the percentage of people aged 45 and older who had 2 or more chronic illnesses increased substantially, the Centers for Disease Control and Prevention reported last year. In particular, hypertension increased from 35% to 41% and diabetes from 10% to 15%. In 2009, chronic illnesses accounted for 75% of health care costs.Even a small reduction in the rate of increase in health care costs can help the system avoid substantial cuts through other, more onerous methods.

Accountable care organizations put the responsibility for care decisions into the hands of clinicians instead of insurers. The greatest cost savings are expected when a payer uses either a bundled payment method (in which an “episode of care” for a patient with congestive heart failure, for example, would encompass care given before, during, and after a hospitalization) or a capitated payment method (in which an ACO would be paid a per-person-per-month amount for all of that patient’s care).

As a Pioneer ACO, Montefiore operates under a capitated payment method with Medicare, meaning it shares in both the financial risks and the savings. But there are many more health systems that participate in the Medicare Shared Savings Program (MSSP) that share in only the savings—at least for now—and can continue to operate under a fee-for-service (FFS) payment method. In theory, if the Potenzas participate in an MSSP ACO, rather than join Montefiore, they would continue to receive an FFS payment, with the hope of receiving a bonus if they continue to manage patients in ways that produce good outcomes and cut costs. But some have argued that keeping the FFS structure will encourage physicians and other providers to focus on volume instead of care management.

Culture Change and Patient Engagement

The success of ACOs depends on a huge culture shift in US health care. First, primary care will need to be the centerpiece, rather than a feeder, for hospitals.

Second, improved care coordination is key to the success of ACOs but will require appropriate infrastructures and processes. This includes information technology to provide data on patient outcomes and care, criteria for which patients need a particular level of care coordination, and a plan and workforce for providing the coordination at these levels. Burke gives examples of how various MSSP ACOs in New York are approaching care coordination.

Third, engaging patients in wellness and self-care management will be rewarded. “Patient engagement” is the new buzz word, and ACOs will have to help patients develop healthier lifestyles and better manage their chronic illnesses. Doing so will entail educating and counseling patients about their illnesses and treatment options, as well as coaching them in lifestyle change. It will also require that physicians and other health care providers listen to what patients and their families say they need and want—not tell them what they need.

Fourth, a shift in focus to population health is expected of ACOs, but that will require sophisticated health information technology that few providers have. Burke points out that payers have these systems, but many health care providers do not. Nonetheless, Dominica Potenza’s Doctorate of Nursing Practice program is providing her with a population health focus. In one assignment, she compared the hospital readmission rate for patients with chronic heart failure in her own practice with that of the Bronx overall. No surprise: the Potenzas’ rate was lower.

Keeping the Patient at the Center

Diligent care coordination and patient engagement is a hallmark of the Potenzas’ practice. While they struggle to adopt a suitable health information technology system, theirs is the old-style neighborhood family practice where the professionals really know their patients and help them make decisions about their health and health care. If they are already doing this, why would they become part of an ACO?

They may have no choice. Montefiore and other ACOs represent a grand experiment in improving population health while reducing costs. But we’re only at the beginning. Almost by definition, ACOs must develop into large, integrated delivery systems, engulfing practices like the Potenzas’. I hope that the Potenzas and others like them will continue to remind us to keep the patient at the center of the experiment.

About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
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