A survey of hospital participation in accountable care organizations shows that many ACOs are physician-led and the delivery system is evolving toward more preventive, primary and coordinated care, but the results also suggest continued challenges in creating an ACO infrastructure that can take on the financial risk, according to Anne-Marie Audet, chief author of a Commonwealth Fund issue brief on the subject. The study's finding that only 13 percent of hospitals are either participating in an ACO or plan to become involved in the future shows that hospitals are still very much at the beginning of the ACO adoption curve, Audet said.
The Commonwealth Fund brief analyzes the results of a survey conducted May to September 2011 by the American Hospital Association's research arm, and Audet says that the percentage of hospitals participating in or interested in ACOs is lower than expected.
The results are good news for the American Medical Association. "The AMA strongly advocated that ACOs be structured in a way that encourages participation by physicians in all types of practice organizations," AMA President Jeremy Lazarus said in an emailed statement. "We are pleased to see data that suggests most ACOs, even those with significant hospital involvement, are physician-led, as physician leadership will be the key to ACO success."
This also signals that these types of delivery and payments models are changing the paradigm and promoting care that is driven by more primary care, longitudinal care and population management, Audet says.
Audet has already received a grant to study ACOs formed by physician group practices and will begin that survey in September. She also has linked up with the Pacific Business Group on Health's Catalysts for Payment Reform to collect information on health plans entering into more complex payment models. She also plans to work with the National Academy of State Health Policy to take a look at what state Medicaid programs are doing. The duals population could be a major beneficiary of the ACO model, she notes.
The survey found that hospitals have been developing strong partnerships with other providers and payers and that payment reforms and delivery forms must go hand in hand in order to be successful. "New models of payment are not likely to be successful if the delivery system is not ready to receive them; alternatively, new delivery approaches must be sustained by payment approaches," the study says.
Of the respondents that are participating or plan to participate in an ACO, the majority are linked up with commercial payers, including self-insured employers. Sixteen percent of the respondents were pursuing partnerships with Medicaid ACO programs, and 14 percent planned on joining the Medicare Shared Savings Program, however, the study notes that the MSSP rules had not been finalized at the time the survey was out. Audet says the findings likely would not have changed much from 2011 if conducted now, but she would expect to see a uptick in participation if the study were to be conducted next year.
Hospitals said they expect an 11 percent decrease in fee-for-service payments over the next three years, and hospitals that plan to participate in ACOs expected to see a 10 percent gain due to the FFS plus shared savings model, the survey found. Bundled payments were expected to bring gains of 8.1 percent and capitation another 5 percent, the study says. The majority of hospitals (52 percent) that are participating in ACOs will be pursing the FFS plus shared savings model, a third of respondents will be doing the two-sided risk model, and the least amount of respondent (26.8 percent) plan to purse partial or global capitation, the survey states.
"These findings support the notion that providers must first establish a care coordination and management infrastructure before assuming financial risk for their assigned population," the study says.
Audet says the revenue expectations may be strong enough to spur change but they also highlight the challenges of assuming risk. A key issue will be the ability of hospitals to get real-time information on utilization, she says, noting that currently CMS readmissions rates are two years old. That is no way to manage a population, she says, adding that a person could not manage their own check book with that type of time lag. The good news, she says, is that systems to track utilization are available.