The U.S. Health and Human Services Department rolled out its inaugural list of Pioneer accountable care organizations, and the surprises came more from location than volume. The initial uproar over the Medicare Shared Savings Program did not hamper interest in Pioneer ACOs. HHS picked 32 organizations from a pool of 80 applicants. The Pioneer ACO track was created for organizations with experience in integration and care coordination. The rewards and risks are more aggressive than in the regular Medicare Shared Savings Program.

Although seniors in 19 states will have access to Pioneer ACOs, the participants are bunched together. Regions with high levels of integrated health systems fared best. California had six. Seven came from New England, including five in Massachusetts. The Upper Midwest had four Pioneer ACOs between Minnesota and Wisconsin, with three more located in Michigan. The exclusion of the sparsely populated Northern Plains was hardly a surprise.

In the entire Southeast, Pioneer ACOs will operate only in Texas (two) and Florida (one). The lack of Florida participants feels odd considering the state's high volume of Medicare beneficiaries. Nearly 32 percent of Florida beneficiaries join a Medicare Advantage plan (HealthLeaders-InterStudy), but the state still has 2.3 million fee-for-service beneficiaries. Miami has the nation's highest per-member, per-month reimbursement rate. One explanation for the Florida gap may be the state's  high concentration of for-profit hospitals, which might be less likely to take a chance on receiving lower payments if outcomes don't improve.

The only common thread among the selected entities is innovation; in coordinated care, that runs deep in California, and the Upper Midwest states, which have quietly built unique integrated health systems. Blue Cross and Blue Shield of Michigan has one of the nation's most successful medical home programs, a sign that Michigan physicians understand the facets of coordinated care. In Minnesota, HMOs must be nonprofit, and Wisconsin's integrated health systems run some of the highestrated Medicare Advantage plans.

The organizations in this pilot cover a broad spectrum of models, many of whom have built integrated care systems suited to their regions. Officials with the Centers for Medicare & Medicaid Services have said they wanted such a mix to gauge the effectiveness of shared savings among different models. Some defy easy categorization. Denver's Physician Health Partners is a managed service organization that coordinates care, negotiates with health plans and handles claims for four IPAs. PHP also helps its physicians transition to the patient-centered medical home model. In Dallas-Fort Worth, a region highly resistant to closed systems like HMOs, CMS selected North Texas Specialty Physicians, a 600-physician IPA that also operates Care N Care and Medicare Advantage PPO.

The Pioneer ACO announcement is a prologue to the bigger announcement of the Shared Savings Program participants coming in Spring 2012. If participants cluster together in the same way, then it may be obvious that accountable care is not available for seniors in every region.

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