Uncertainties, Mysteries, Doubts, and Challenges of Accountable Care Organizations

I mean Negative Capability, that is, when Man is capable of being in uncertainties, Mysteries, doubts, without any irritable reasoning after fact & reason.

John Keats (1795-1821)

January 3, 2011 - The uncertainties, mysteries, doubts, and challenges facing implementation of accountable care organizations (ACOs), just launched this January, are not to be understated.

Consider this statement by the three authors of “Building the Path to Accountable Care,” (New England Journal of Medicine, December 29, 2011).

Its three authors, Elliot S. Fisher, MD, of the Dartmouth Institute for Health Policy and Clinical Practice, Mark B. McClellan, MD, of the Brookings Institute, and Dana G, Safran, Sc.D. of Blue Cross Blue Shield of Massachusetts, state:

"Implementation is still at an early stage. We have preliminary information about the actual performance of many ACOs and no strong evidence on which features are most likely to lead to success in specific circumstances or how ACOS can be integrated with other reforms intended to promote accountability and high-value care. On the basis of the growing set of ACO experiences and the intensive public comments regarding the Medicare ACO program, we have identified five key challenges and possible approaches to overcoming them."

In other words, the three do not know precisely what to expect.
They list these challenges.

One, providing timely data and useful performance measures to support case management and quality measures to improve care within the ACO own setting. Builders on ACO may be blind to care other ACOs provide. It is a venture into the unknown.

Two, overcoming transition costs to support investments needed to start up ACOs and to provide funding for poorly capitalized groups. ACOS are expensive to set up from scratch. How expensive no one knows.

Three, gaining Medicare population support for a new kind of care that at this point means nothing to Medicare patients. Medicare recipients may perceive ACO as stinting on care and forcing them to switch doctors or hospitals.

Four, learning what works and doesn’t work and using what is learned to inform policy and practice. ACOs are a learning experiment. Where and how they end up no one knows for sure.

Five, clarifying the path forward and how to create an unknown alternative to fee-for-service and to give physicians some idea whether ACOs will provide them with an adequate income and a new and satisfying practice experience.

The reason of the authors give for building ACOs is that fee-for-service payments for non-ACO practitioners will undergo an “inexorable transition “ which “will almost certainly see continued cuts in payment rates.”

Inside-the-ACO-Box Thinking

The problem with the authors’ assumptions is this. They are thinking exclusively inside the ACO box. They are avoiding obvious questions.

Why should 90% of doctors who practice outside ACOs accept the idea of a risky experimental model? The model may not provide them with adequate income. It may impinge on their practice freedoms and incomes. It may force them to practice ACO-type medicine on their non-Medicare patients. It may compel them to change existing practice patterns and to junk existing practice management systems, which are based on fee-for-service systems. It is difficult to change practice stripes between patients in the same practice. What are the consequences if the ACO fails? What are the anti-trust risks if the ACP succeeds?

How does the ACO model anticipate dealing with these physician options?

Physicians may choose not to join the ACO, not to accept new Medicare patients, to retire, to enter concierge or other direct-cash practices, to pursue medical careers outside of clinical practice or outside of medicine.

What happens if the Supreme Court overturns Obamacare in part or as a whole? And what will take place if Republicans win the presidency, the House, and the Senate – and repeal Obamacare?

There are simply too many uncertainties, mysteries, doubts, and challenges for most physicians to contemplate before embarking on an ACO.

Therefore, many, if not most physicians, are likely to adopt a “wait-and-see” attitude. This srikes me as the prudent thing to do.

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