Accountable Care Organizations and Risk

Despite the fact that several organizations dropped out of Medicare’s Pioneer ACO program, Ateev Mehrotra, MD, MPH, associate professor of healthcare policy and medicine at Harvard Medical School, argues that “The ACO program has been successful: In aggregate, many of the ACOs are decreasing costs,” and quality of care has improved. However, he does have concerns, including how these programs have been implemented and levels of risk. He sees the next generation of ACOs as being a path between the Pioneer and Shared Savings models. This new model may be to allow providers to take on additional risk, according to Dr Mehrotra.

Arthur Vercillo, MD, FACS, regional president, Excellus Blue Cross Blue Shield, points out, “There are some incredibly sophisticated health delivery systems that know how to assume risk,” but physicians and smaller hospitals should be well informed and should proceed slowly with risk taking. Although there are many bright, hard-working providers, they may be surprised by what can eventually happen after the documents are signed, he cautions, even if they think the risk implications are understood.

Dr Scanlon, the Summit moderator, emphasizes that this was the problem with physician—hospital organizations in the 1990s—they were ill-equipped to assume risk. But risk can be managed through novel reinsurance programs, which may provide coverage for noncatastrophic cases.

There could be solutions to help equip providers to take on financial risk, agrees Francois de Brantes, MS, MBA, executive director of the Healthcare Incentives Improvement Institute, “which may be variations of insurance risks.” He claims that the country has not had an intelligent dialogue about differences in risks involving quality of technical expertise, managing patients more effectively, or reducing infection rates, “and how to plan for boundaries around those risks.” We have to “understand the implications of the different types of risk that exist in healthcare,” Mr. de Brantes states, and understand control, distribution, and variability of the risk.

It is difficult for an organization that was built on one model for 50 years to shift to another, says Dr. Mehrotra. “It just does not happen overnight.” He added, “I’m part of an ACO. I practice in an ACO. But at the end of the day, I’m not sure what, in terms of the care delivery that I provide, has changed in any observable way from my end as a doctor, than it was 5 years ago when we weren’t part of an ACO.”