The original fear of accountable care organizations was that they would turn into monoliths, with healthcare within a particular metro area dominated by two or three companies, each one a Gordian knot of payers, providers and hospital facilities. What we are seeing now are smaller, physician-led ACOs dotting the country, more grass-roots than trickle down. With many health systems shunning CMS-approved ACO projects, does this mean the end of accountable care as envisioned by the Affordable Care Act?

The conventional thinking had been that for ACOs to take off, hospitals must get on board. ACOs are collections of medical providers paid to care for a group of patients, instead of being reimbursed for each service provided to each patient. They share in savings if they reduce the cost of care and improve quality. A year ago, when the early draft rules for accountable care organizations started to emerge, there was a lot of hand-wringing about what hospitals would think, and how the rules were too onerous. Later in the fall, when the more relaxed final rules were issued, hospitals in general still didn't bite.

There has been the presumption that this rejection by hospitals spelled doom for the ACO model, because hospitals were viewed as the natural leaders for these endeavors. They had the organization, the capital, the payer arrangements, the infrastructure, the branding. But hospitals were also adverse to risk, and some health systems have had a tough time convincing physicians that the hospital has their best interests in mind.

In Florida, for instance, while health systems such as BayCare in Tampa, Orlando Health and Baptist Health South Florida are employing physicians to lay the foundation for ACOs, physician groups are leading the charge into the model, reflecting a national trend. There are three Shared Savings ACOs in the Sunshine State (Florida Physicians Trust in Winter Park, Primary Partners in Central Florida, and West Florida ACO), all comprised of independent physicians. The state's lone Pioneer ACO (JSA Healthcare in Tampa) is an independent physician group as well. Health systems in Florida, on the other hand, have been largely quiet on the matter.

A practice like JSA already had significant experience with electronic medical records and Medicare Advantage going in, both useful for getting into the ACO model. While hospitals may be reticent about risk, physician groups that have already contracted with, and reaped the rewards of, Medicare Advantage plans see opportunity. Particularly in south Florida, where per-member, per-month reimbursement for managed Medicare is extremely generous, practices have made a lot of money by taking on some risk and demonstrating that they meet quality and efficiency standards.

EMR and MA experience is good, but the catalyst for physician-led ACOs may be distrust between physicians and large health systems. The efforts by large health systems throughout the state to get more physicians on board have been met with suspicion by the medical community. Physicians are extremely skeptical of health system bureaucracy, especially in states like Florida and Texas, where powerful physician lobbies foster an independent streak in the medical community. Instead of hooking up with hospitals, many practices are banding together to form single-specialty "super-groups
". By staying independent of hospitals, these super-groups can be perpetual free agents, with hospitals vying for their services. This dynamic is particularly true in competitive hospital environments like Dallas, Tampa, Miami and Houston.

This is not to say that health system s have entirely eschewed the ACO model; changing reimbursement models dictate more coordination of providers. Advocate Health Care in Chicago, Banner Health in Phoenix, and OhioHealth in Columbus are just a few of the major health systems that are heavily invested in an ACO or something very similar. But these hospital-led ACOs, often confined to highly consolidated markets, may prove to be the exception to the rule.

Which brings us to the question: why did we think that health systems were going to be the tentpole for the ACO model. Expensive hospital stays are what you want to avoid if you are employing a shared savings model. As commercial health plans such as Aetna, UnitedHealth and WellPoint have recently demonstrated, if you want to coordinate care and efficiency, the incentives need to be directed to the physician. Shifts in the standard reimbursement model toward greater coordination of care, with incentives for cost efficiency and higher quality, are here to stay, regardless of the Supreme Court's ruling on Obamacare. Indeed, the larger health systems may be waiting for a ruling before going whole hog into ACOs. But for innovation in the ACO, and a clue to where the model is moving, keep an eye on physician groups.

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