Successful ACOs say they struggle to get physician issues ironed out

Four accountable care organizations that are meeting their goals in increasing quality of care while controlling costs say not everything is working out to their satisfaction — particularly, transitioning from fee-for-service to value-based payment models.

An August report by Premier Research Institute, a nonprofit foundation, and the Commonwealth Fund looked at the goals, challenges and outcomes of four early ACO adopters — Fairview Health Services in Minneapolis; Memorial Health Care System in the greater Miami area; Presbyterian Healthcare Services in Albuquerque, N.M.; and AtlantiCare Health Solutions in Egg Harbor Township, N.J.

These health systems showed promising results. AtlantiCare reported a 40% drop in hospital admissions. Fairview said colon cancer screenings were up from about 62% to nearly 70%, and patient utilization was down by about 13% in one year. Memorial saved the state health department $20 million, and Presbyterian improved care management and reduced costs through oversight of entire care episodes.

But the report said pacing of the shift to new payment models for physicians was a stumbling block.

The pacing problem is because of the challenges of setting up fully integrated coordinated care systems while trying to simultaneously change the payment models to reward physicians based on value, efficiency and outcomes, rather than merely on a fee-for-service basis, said Steve Blumberg, senior vice president and executive director at AtlantiCare Health Solutions.

“I think it becomes important for clinical integration and payment reform to move along in lockstep, so you don’t have one of those levers too far in front of the other,” Blumberg said.

In some cases, ACOs’ transitions have been made harder by miscalculations along the way, said Eugene Kroch, PhD, vice president and chief scientist at Premier.

In general, some hospital executives who headed ACOs tended to be more focused on payment models when it was later realized it was better to focus on implementing coordinated care, he said. That’s because of the two, care coordination is much harder to achieve, he said.

“Another problem that became obvious to us — top executives don’t have the experience in what is highly disruptive changes that ACOs demands,” Kroch said.

Presbyterian reported that a shortage of primary care doctors and other practitioners could have a significant effect on access and capacity in the future as it transitions to patient-centered medical homes.

Another issue has been getting payers to make the transition as well. Blumberg said some payers have been quicker to jump on the new payment models than others.

Most health plans have been advocating a move away from fee for service and will continue to do so, said Susan Pisano, vice president of communications for America’s Health Insurance Plans.

“I think it’s not one of those things where it happens overnight,” Pisano said. “But I do think providers are seeing the need for this and are working with health plans.”

A slow move

The Premier report’s discussion of difficulties with payment issues echoes what some ACOs have said previously. In February, ACO executives at a National Committee for Quality Assurance webinar said reluctance of some health professionals and payers to accept the model fully has resulted in a slower transition from fee for service to value-based payments.

The transition to value-based care has worried many doctors, especially specialists, said Harold Miller, president and chief executive officer for the Center for Healthcare Quality and Payment Reform.

In fee for service, doctors are paid for what they do. During a transition to a value-based system, it’s not clear how doing less will pay them the same amount, he said.

“If I’m in an independent practice, I need enough money to come in, and the only way I do that is by doing things,” Miller said. “But if I do fewer things, I’ll lose money today and hope that there is some shared savings, and there might not be.”

In ACOs, more emphasis is put on primary care doctors to coordinate care. Many AtlantiCare specialists were worried that increased primary care services would decrease their incomes by reducing the number of patients that came to see them. But that didn’t pan out, Blumberg said.

While it was true that primary care doctors are taking care of more patients with chronic problems, which has prevented them from seeing other doctors, it allowed specialists more time to see other patients who needed their care, he said.

“I’m sure that there are concerns that the change in the economic model will disrupt the current environment,” Blumberg said. “But most are trying to navigate that rather than resist it, and most understand that health care is too expensive.”