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Are Doc-Led ACOs Better? The Jury’s Still Out, Say Healthcare Policy Researchers

June 22, 2014
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If there’s one thing that we at Healthcare Informatics have been stressing for years now, it’s that physician engagement is absolutely crucial to the success of any IT implementation, from the rollout of a core electronic health record to the leveraging of information systems for data analytics and population health management. That remains a core message from this publication, for many good reasons.

But I have to admit I found an article in the June issue of Health Affairs  exceptionally intriguing. The article, entitled “First National Survey of ACOs Finds That Physicians Are Playing Strong leadership and Ownership Roles,” and authored by Carrie H. Colla, Valerie A. Lewis, Stephen M. Shortell, and Elliott S. Fisher, provided analysis based on a first-ever nationwide survey of accountable care organizations that looked at some of the differences between those being led by physicians and those being led by other entities (primarily hospitals).

In their survey of 173 ACOs nationwide, the researchers found that 51 percent of ACOs were physician-led, with another 33 percent jointly led by physicians and hospitals. In 78 percent of ACOs, physicians constituted a majority of the governing board, and physicians owned 40 percent of ACOs. “The broad reach of physician leadership” in ACOs, the authors noted, “has important implications for the future evolution of ACOs. It seems likely that the challenge of fundamentally changing care delivery as the country moves away from fee-for-service payment will not be accomplished without strong, effective leadership from physicians.”

At the same time, digging a bit more deeply, the authors also found some concerning issues emerging among physician-led ACOs, compared with other models (primarily those led by hospital organizations). First, they expressed concern over the capability of physician-led ACOs to access the capital needed to sustain their ventures. But beyond that, they also found that physician-led ACOs were prone to lacking the intensive infrastructure needed to manage transitions of care and to avert readmissions, particularly if those ACOs lacked the core hospital involvement needed to manage those two vital areas.

Interestingly, the authors found that physician-led ACOs were as likely or unlikely as other types of ACOs to have the needed IT infrastructure for ACO development; but also that overall, fewer than half had the advanced capabilities in care management and IT infrastructure development (they did not distinguish between the two in the survey, but instead grouped them together as a single combined capability).

How concerning is this? Well, potentially, quite concerning. One of the unsaid elements in all this is the fact that, for many practicing physicians in the U.S., the intense reimbursement, policy-and-regulatory-mandate, market-competition, and other pressures hitting them right now, are combining to make practicing physicians in this country feel more pressured than ever, on multiple fronts. Indeed, every week, a new survey seems to emerge that finds that physicians are more discouraged than ever, with fewer and fewer expressing the wish that their children might follow in their footsteps and become doctors themselves.

What’s more, as we’ve been finding regarding the Medicare Shared Savings Program (MSSP), both Pioneer and “regular,” the sledding so far has been rougher than many might have expected, with the shared savings and clinical outcomes less impressive than the folks at CMS (the Centers for Medicare and Medicaid Services) had probably hoped for; indeed, the announcement a year ago that seven of the Pioneer Medicare Shared Savings Program (MSSP) participant entities were shifting to regular MSSP status after failing to produce the level of cost savings expected of them under the terms of the Pioneer MSSP program, and two were leaving the MSSP program altogether, was greeted with a collective gasp by many in the industry.

Still, ACOs are moving forward generally, and there are currently 368 MSSP ACOs and about 500 ACOs of any kind (depending on who’s counting) operating across the U.S.; and every week, a new ACO of some kind is announced.

But the notes of caution in this new Health Affairs study are worth pondering, since really, ultimately, it will take a very big collective leap forward among American physicians generally, to make accountable care work in the broadest sense of the term, and everyone knows that. Physicians remain the group primarily responsible for making the moment-to-moment utilization decisions in U.S. healthcare, and their embrace (or lack of it) of the new, transparent, accountable, performance-driven, and value-based-purchased healthcare, will make all the difference going forward. What will be absolutely essential, of course, will be the emergence of full alignment among all the stakeholder groups—physicians, hospitals, post-acute care, health insurers, employer-purchasers, and government-purchasers, and consumers/patients, for the new, emergent species of healthcare delivery and financing models to work.