Disease-specific ACOs make their debut

A small number of entities are testing the accountable care organization concept, originally designed to improve care and reduce costs for populations of primary care patients, on groups of people with high-cost diseases such as cancer or end-stage renal disease.

“I would expect an increasing number of disease specific accountable care ventures to develop over time,” said John Redding, MD, a manager at Indianapolis-based Blue Consulting Services. “These ventures would focus on conditions that are chronic, high cost and highly prevalent in our society, and place a high burden on patients' quality of life.”

For instance, Florida Blue, formerly Blue Cross and Blue Shield of Florida, announced Dec. 20, 2012, the launch of an ACO for cancer patients cared for by the Moffitt Cancer Center in Tampa, Fla. This was the second such project of this type by the insurer. The first, with Baptist Health South Florida, a large health system in the Miami area, and Advanced Medical Specialities, an oncology group also in Miami, was announced May 4, 2012.

DaVita, a Denver-based dialysis provider with 1,912 outpatient centers in the U.S., launched the Accountable Kidney Care Collaborative and is working with commercial and government insurers to set up pilot ACOs for this population. In June 2012, the company acquired HealthCare Partners, a large multispeciality group practice with 700 employed physicians, a network of 8,300 independent doctors and two ACOs focused on primary care patients. These ACOs will be the models for the disease-specific ones.

“ESRD patients are such a small patient population but have such significant medical needs,” said Allen Nissenson, MD, DaVita's chief medical officer. “They can get lost in a general ACO.”

These types of ACOs work a lot like the ones that have emerged in recent years. Physicians collect fees for services provided and a share of any savings if certain quality benchmarks are met. Insurance company partners provide administrative and data support. Much like the early adopters of this model, those developing disease-specific ACOs are large players in their markets, although consultants say they may spread to smaller practices later.

Disease-specific ACOs can be particularly appealing, say consultants, because reducing costs among more expensive patients may provide more value than those who cost less money. According to the United States Renal Data System, in 2010, Medicare spent $32.9 billion, or 6% of total program expenditures, on end-stage renal disease. Medicaid and commercial payers spent a total of $9.8 billion. National Cancer Institute data indicate that $124.6 billion was spent on cancer treatments in 2010.

Same look, different strategy

Primary care-oriented or total care cost ACOs always will include at least some patients with cancer or ESRD, but more disease-specific projects are in the works. And there are definite differences.

For one, the benchmarks are different. Commercial insurer ACO programs will vary widely, but the quality performance standards for Medicare ACOs include numerous measures for the prevention and screening of cancer and renal disease. There are none for treatment of these conditions. The disease-specific ACOs said they, comparably, are focused on improving care for these conditions.

Disease-specific ACOs also are looking at slightly different strategies to reduce costs. Those working on ESRD are identifying ways to cut hospitalizations. Those focusing on cancer are looking to standardize care protocols and help patients navigate the copious amounts of information that can follow a diagnosis.

In the case of cancer, the best care may mean watchful waiting, which the ACOs acknowledge could lead to a physician, health system or insurer being accused of withholding treatment to save money. Those designing ACOs for cancer patients say physicians will be in charge of designing care protocols. In addition, there are numerous studies documenting that, in some cases, watchful waiting or less intensive interventions are the best actions.

“The clinical pathways we are using were developed by our doctors who are looking after patients with specific cancers,” said Johnathan Lancaster, MD, PhD, president of the Moffitt Medical Group. “You can't simply cut costs and compromise quality, because then you spend more money in the long term.”

There also will be work to increase patient engagement in their own care and address the needs of family members and other caregivers in hope that these efforts will translate to reduced costs and reduced outcomes.

“If [patients] don't have the right support systems in place, you're going to need to help them get connected to the right support systems,” said Richard Weil, PhD, a partner in the health and life science practice at Oliver Wyman, a New York-based company that consults with health care institutions looking to set up ACOs.

Another key difference is that most general population ACOs have primary care at the center, but that is not the case with those that are disease-specific. Some primary care physicians will find themselves providing primary care to patients within the disease-specific ACO. Other primary care physicians may find themselves referring patients to these ACOs. Organizers say primary care is still important in disease-specific ACOs, because one way to reduce costs is to improve care of conditions unrelated to the focal disease.

“The more we communicate with primary care physicians, the better the outcomes will be for our patients,” Dr. Lancaster said.