Do ACOs Matter to Anesthesiologists and Pain Physicians Yet?
In meetings and conferences where the presenter asks anesthesiologists and pain physicians whether they are participating in—or negotiating with—an Accountable Care Organization (ACO), very few, if any, of the doctors raise their hands. Everyone is aware of the concept of ACOs, but almost no one has any experience with them yet. Nevertheless, there are significant ACO developments across the country.
Tens of millions of patients are already receiving medical services through ACOs. A year ago—even before the United States Supreme Court’s decision upholding most of the Affordable Care Act—32 ACOs were participating in the Medicare Pioneer demonstration program and 27 more had signed up to become Medicare ACOs. Becker’s Hospital Review briefly described 80 Accountable Care Organizations to Know, both commercial and Medicare, in an online article dated April 16, 2012. Many of these ACOs were formed by hospitals and health systems in partnership with health plans. They range in size from as few as 5,000 patients (Physicians of Cape Cod ACO) to a potential one million or more (Carilion Clinic, Roanoke, VA, together with Aetna). Among the oldest is Partners HealthCare in Boston (“The system's background with care coordination stems back to 2006, when the system's Massachusetts General Hospital in Boston launched the Care Management Program, one of six CMS demonstration projects in the country. The program was found to be so successful—for every dollar spent, the program saved $2.65 in healthcare costs—that in 2009, CMS renewed it for another three years and expanded it to two more Partners hospitals.”).
In a January, 2013 report from the National Academy for State Health Policy (NASHP), Mapping Accountable Care Activity in the States, the author notes that “patterns have begun to emerge in state approaches to fostering accountable care.” Some approaches involve ACOs as such; others foster organizations that assume responsibility for a defined patient population across a continuum of care in different ways, as the report summarizes:
- Maine is designing an Accountable Communities initiative that is designed to mirror the federal Medicare Shared Savings Program.
- New York’s Department of Health is launching a program to certify ACOs.
- New Jersey plans to launch a 3-year Medicaid ACO Demonstration Project.
- Massachusetts will use ACOs, certified by a new Independent Health Policy Commission, as a key component of the state’s cost control strategy.
- Texas is developing a certification process for health care collaboratives, new entities composed of physicians and providers that can enter into innovative payment arrangements with public and private payers to assume responsibility for a range of health care services.
- Illinois has launched Care Coordination Entities (CCEs), collaborations of providers and community agencies, governed by a lead entity that receives care coordination payments in order to provide care coordination services.
- Minnesota’s Health Care Delivery Systems Demonstration will reward groups of providers and integrated delivery systems that can achieve savings below a total cost of care target while meeting quality performance requirements.
State governments’ efforts thus far have been largely directed toward creating, in statutes and regulations, the conditions for certification of ACOs. Most of the ACOs noted in the NASHP report are still in the planning stages.
The National Committee on Quality Assurance (NCQA), a private organization that has been accrediting health plans since 1990, began accrediting ACOs in 2012. It evaluates ACOs in seven categories:
- ACO Structure and Organizations
- Access to Needed Providers
- Patient-Centered Primary Care
- Care Management
- Care Coordination and Transitions
- Patient Rights and Responsibilities
- Performance Reporting and Quality Improvement
Kelsey-Seybold Clinic in Houston became the first ACO to receive NCQA accreditation last December. The NCQA grants three different levels of approval representing varying degrees of capability for coordinating care and reporting and improving quality. Kelsey-Seybold and two other ACOs are at Level 2 (“Organizations demonstrating well-established capabilities outlined in the standards to meet the triple aim of better patient experience, better health and lower per capita cost”); there are no Level 3 organizations (“Organizations demonstrating strong performance or significant improvement in performance measures across the triple aim”) yet.
Although some of the “80 Accountable Care Organizations to Know” have primary care physician-to-specialist ratios upwards of 8:1, there is scant evidence—on the web or anecdotally—of anesthesiologist or pain physician participation, although presumably some of the numerous hospital-based ACOs must contract for anesthesiology and pain care in one form or another.
As Brenda Morrow wrote in her April, 2011 article Accountable Care Organization Strategies for Anesthesiologists, published in Becker’s Hospital Review, “Anesthesiologists and other hospital-based physicians will initially have a limited role in overall Medicare ACO outcomes. In its first iteration, the nucleus of a Medicare ACO is primary care.”
It is not clear that anesthesiology’s role has developed significantly since Ms. Morrow noted the relevance of two of the quality measures initially proposed for Medicare ACO reporting were within the specialty’s domain: catheter-related bloodstream infection prevention and antibiotic prophylaxis. Most of the published commentary describes and advises on future anesthesiology and pain medicine involvement, e.g., How Interventional Pain Management Will Contribute to ACOs: Q&A With Dr. Scott Glaser (Becker’s Spine Review, November 8, 2010) (closer monitoring of narcotic usage post-operatively and in the pain clinic, where prescription painkillers do not target the source of the pain and may not work long-term, unlike interventional techniques, could reduce the number of narcotics overdoses and of hospital admissions due to complications of prescription drug abuse).
One of the more interesting prospective discussions is in Somnia Inc.’s March 2011 white paper The Role of Anesthesia in Accountable Care Organizations. Answering the question as to why anesthesia should play a key role in ACOs, the authors write:
Anesthesia touches and influences so many different care areas throughout an acute or ambulatory facility that its participation and support is critical to the sustained success of an ACO.
The anesthesia clinician can be thought of as the “procedural intensivist” in both the acute and ambulatory setting as they serve as the primary provider in the assessment and management of the patient’s care along the continuum in most surgical, procedural and obstetrical areas. Thus, it makes sense that the anesthesia providers be held “accountable” for managing the overall quality of care and cost efficiencies related to those critical care areas. In essence, your anesthesia providers/service should be viewed as an “accountable anesthesia organization” within the larger ACO.
The paper then introduces the concept of an Accountable Anesthesia Organization™ (AAO) as “a transparent, collaborative partner in the ACO. Its goals are aligned with the structure of the ACO and center on transparency, resource utilization, quality metrics, cost containment and patient experience.”
We have all been talking about anesthesiology and pain medicine being integral parts—or even leaders—of ACOs for several years now. The challenges of participation are great, but they are becoming familiar. We look forward to bringing our readers news of how anesthesiologists and pain physicians have met some of those challenges.