Designing the Perfect ACO

By Kim Bellard, May 4, 2011

Accountable Care Organizations (ACOs) are supposed to be the way forward in improving our health care system.  CMS has recently released proposed rules around Medicare ACOs that help detail the requirements, with Medicare getting ready to start making funds available for ACOs as early as 2012.  The private sector is expected to follow in Medicare’s footsteps with their own versions of ACOs.

Since ACOs hold the prospect of being the new delivery system for many or even most Americans, I wanted to propose my own wish list for what I hope will be true of the ACO experience:

• I want to go to an ACO physician knowing something meaningful about him or her.  Not just the standard medical school/board certification/professional designation information, but facts that give me insight into actual (and recent) performance.  I.e., what is the profile of the patients he/she sees?  How well do patients with chronic conditions receive the recommended set of services?  For physicians doing procedures, how many do they do, and what are their outcomes?   Perhaps most importantly, what do patients report about their experiences with this physician?  And not just current patients, but also former patients; e.g., are they former patients due to no continued need, or due to a bad experience?
• I think it is entirely fair that better-performing physicians get paid more, whether by me (via my cost-sharing) and/or by the ACO/insurer.  In fact, I think it is downright dangerous if that does not happen.  If everyone gets paid the same, the more likely it is that everyone performs the same, and I want my physicians striving to be the best.
• I want the physician to have my medical records readily available – not just from prior encounters with him/her, but including all the relevant information from all of my recent encounters with the health care system.  E.g., tests, imaging, prescriptions, reports from other physicians (primary care or specialists).  Presumably this speaks to a unified electronic health record -- permission-based, of course.  He/she needs to know the whole picture, and I don’t want to keep trying to accurately fill out the same or similar forms each time I see a provider.
• I want access to my health records.  Not in the same language and format as the physician sees them, but based on the same information, yet in a consumer-friendly version that helps make my health history understandable and actionable, so I can do my best to maintain and improve my health.  I should be able to provide my own input into the records, some of which would be purely for myself and some of which could provide additional insight for my physician(s).  After all, when it comes to reporting my own health, who better?
• I want the physician to be reminded of any medically indicated actions for me; e.g., am I not refilling my prescriptions, is it time for a preventive test or procedure, were there concerns from prior visits that should be followed up on?   Physicians are generally very smart people, but the data are pretty clear that many patients are not getting all of the recommended services and oversight.  We shouldn’t rely solely on the physician’s memory to help remind them what should be happening, and when, with me.   For that matter, I want to be reminded as well.
• I want to know that the physician is not acting solely on his/her own for my treatment, that there is some effective peer review in the ACO that monitors the care he/she is providing, and actively provides feedback.  It’s not about suspecting the physician is doing a bad job; it’s about instilling an attitude of always wanting to do things better.  Measurement and feedback loops are Quality Improvement 101.  Physicians are notoriously independent, but that is not an attitude that leads to strong QI.
• I want to make sure my physician and I use the most efficient mechanisms to communicate.  Sometimes he/she needs to see me in person and “lay on the hands,” but many issues can be handled through other mechanisms like texting, email or video.  How and where we communicate shouldn’t be driven by insurance reimbursement concerns, but by what is most time-effective and medically appropriate.
• I want my physician to help coordinate any other testing/treatment I need.  E.g., not just refer me to another physician or imaging center, but help arrange the visit.  And I certainly expect that I would not need to tell that referred provider why I am there or to recount my history all over again.  They should have access to my records, know what the plan is for me and their role in it, and when they finish make sure everyone involved has most updated information about me.
• I want to have a single bill.  I understand, although I don’t like, that in our health care system lots of entities seem to come out of the woodwork when there is billing to be done, but an ACO should be able to consolidate all that into a clear, unified bill covering anyone they’ve gotten involved in my care.  I hate getting bills from health care professionals or entities I’ve never heard and/or for services that I wasn’t sure I’d had.  And I don’t want to be billed until they’ve worked everything out with the insurance carrier.
• I want reassurance that the professionals treating me don’t simply get paid by doing more things to me, or get paid the same regardless of how well they treat me.  I don’t think either a fee-for-service or a salaried approach is inherently evil; both need to be coupled by rewards for getting good outcomes and penalties for poor outcomes, which include providing unnecessary or inappropriate care.  To be fair, though, physicians shouldn’t be penalized if I am non-compliant or remain passive about taking active efforts to maintain or improve my health.  Splitting those hairs is going to be tricky.

The good news is that none of these are unachievable even in the current health care system.  One can probably find a few integrated delivery systems that already accomplish many of these goals.  The bad news, of course, is that none are doing all of these, and most consumers don’t have access to a delivery system that does even a majority of them.  That’s assuming we can get agreement on how to accomplish them, particularly measurement of and reporting on physician performance.  We have a long way to go...