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Delbanco: Yes, though we have to separate out what might happen under the Medicare Shared Savings Program and what might happen in the private sector, where everyone's trying to feel their way forward. Personally-and this wasn't in the study-I believe that there's a lot of work that has to be done here [to the proposed ACO regulation under the Medicare program], because it's a little awkward to hold a provider responsible for the care of a patient who doesn't want to be a part of the arrangement; that's difficult. At a minimum, if the provider were given information about where that patient did seek care, or whatever, perhaps there's something to be said for that; but as long as there's competition in local markets among providers, I don't see that happening. And we'll all find out what happens in the Medicare Shared Savings Program, but there are lessons being learned in the private sector.
HCI: What do you see as the major lessons overall that are being learned in the private sector to date?
Delbanco: While the feds heard that there was lots of risk-sharing being created in the private sector, what we found out is that that's not true at all; there are very few cases where mature arrangements have created full menus of financial risk and quality outcomes triggers. For instance, in the Medicare program, there are two paths, one where they take on risk in year one and the other where they take on risk in year three, and few are ready for either of those. And my bias, as someone who works with purchasers and employers, is that I do think that providers should assume shared risk in the future; but I don't want us to go into this so fast that we fail; so we do have to be thoughtful about how we help providers assume shared risk.
I BELIEVE THAT THERE'S A LOT OF WORK THAT HAS TO BE DONE HERE [TO THE PROPOSED ACO REGULATION UNDER THE MEDICARE PROGRAM], BECAUSE IT'S A LITTLE AWKWARD TO HOLD A PROVIDER RESPONSIBLE FOR THE CARE OF A PATIENT WHO DOESN'T WANT TO BE A PART OF THE ARRANGEMENT.
HCI: Earlier this year, I spoke with an executive at the American Medical Group Association, who said that his member organizations, which had participated in the earlier Medicare demonstration project on accountable care, were unready for the shared savings program, as articulated in the preliminary ACO rule.
Delbanco: Yes, that is cautionary; and if that's true, then this is an idea that may not be ready yet.
HCI: Do you think CMS [the federal Centers for Medicare and Medicaid Services] will listen to providers' concerns on the Shared Savings Program?
Delbanco: CMS has a history of not wanting to get too far ahead of providers on things. And I have no secret knowledge, but I would guess, just based on past experience, that they would make significant modifications to the final rule.
HCI: Given what you and your colleagues have found from your examination of private-sector initiatives, what would your advice to CIOs, regarding the strategic and operational IT challenges involved?
Delbanco: It's only a question of how quickly, and not whether, shared risk ultimately becomes a part of federal reimbursement. And I would urge them to move forward as fast as they can to monitor cost and quality and implement the systems they need to, because the value-based purchasing program is moving forward quickly now in any case.
HCI: All these programs mandated by healthcare reform are pushing providers forward in a rather clear way, wouldn't you agree?
Delbanco: Yes, absolutely; towards more accountability for quality and for cost.
Healthcare Informatics 2011 December;28(12):40-44
