For one, physicians must sign up for an ACO; with managed
care, it was patients signing up for HMOs. “In this case, the doctors are making the commitment, and they are more involved in the management,” said Fort Worth internist Stuart Pickell, MD, of North Texas Specialty Physi- cians (NTSP). He chairs the Medical Management Committee for a Medicare Pioneer ACO his independent practice asso- ciation (IPA) formed with the Texas Health Resources (THR) hospital system in North Texas.
“In the HMO model, the contract was between a patient and a company that was trying to manage the doctor. Now, the contract is between the doctor and the ACO who work col- laboratively to manage risk by integrating care management, improving quality, increasing patient-centeredness, and reduc- ing redundancies,” he said. Nor are ACOs necessarily closed networks like HMOs were, which means less bureaucracy and more control for physicians. Instead of simply limiting care and costs through prior autho- rizations, for example, which makes it difficult for physicians to access the care their patients need, accountable care em- phasizes quality-based and efficiency-based measures to drive performance. “You can order an MRI when you want. But at the end of the day, your utilization is compared with doctors in similar situations, and you can start to make decisions based on more transparent data,” said Gregory S. Sheff, MD. He is president and chief medical officer of the Seton Health Alliance, another Medicare Pioneer ACO jointly formed by the Seton Healthcare Family hospital system and his independent multispecialty clinic, Austin Regional Clinic (ARC). Physician leaders also say that unlike earlier managed care models, ACOs have the broader goal of managing a popula- tion’s health across the continuum of care and creating the infrastructure to accomplish that. Thomas W. Knight, MD, of Houston, a member of NCQA’s
ACO Review Oversight Committee, notes that the account- able care movement coincides with an overall shift toward “a patient-centered world, and we have to refocus our system around that.” He adds that ACOs are no longer “theory,” with at least 10 percent of U.S. citizens under the care of such organizations. Medicare, private payers, and accrediting organizations like NCQA have differing versions of what it takes to be an ACO. Nevertheless, Dr. Knight says the models do require certain components, including:
• A legal structure that allows participants to function to- gether, whether as a physician-only or physician-hospital organization;
• A physician network that can manage primary care, in par- ticular, but also complex cases, acute episodes, and transi- tions of care;
• The infrastructure to manage cases and measure outcomes across the continuum of care;
• Health information technology; and • A patient experience survey tool.
Moving away from a purely fee-for-service payment system also is a core tenet of accountable care, which means physi- cians and hospitals likely will have to trade some near-term revenue for long-term rewards. That shift doesn’t necessarily mean getting rid of fee-for-ser- vice all at once. But, physician leaders say, ACOs have to find a way to work in incentives to control costs and improve quality. “That’s not going to work in a strict fee-for-service environ- ment” that relies on utilization for revenue, says Dr. Carter, a member of TMA’s Council on Legislation. “There is no CPT code for avoiding an admission. But this is a model that re- wards cost-effective care.” Kelsey-Seybold uses a capitation arrangement and receives
a set per-member, per-month payment from commercial pay- ers to cover those patients’ care, from soup to nuts. It can use savings to improve quality or patient experience or to help compensate physicians for practicing cost-effective, evidence- based care. The group follows a similar model for the Medicare Advantage health plan it operates. As the ACO, Kelsey-Seybold is responsible for monitoring
and directing all patient care, Dr. Carter explains. The physi- cian-only organization does not include a hospital. But it does coordinate with multiple facilities in Houston and contract with affiliated subspecialists, such as pediatric subspecialists, who are not a part of the physician group. Kelsey-Seybold also uses an electronic medical record sys-
tem, a set of quality metrics, and a disease management pro- gram to not only track cost and quality outcomes, but to also keep patients engaged. “We do a fair amount of outreach to remind patients when
they are due for health maintenance, and prior to the idea of accountable care, most people felt that it was the health plans’ responsibility to notify the doctor or patient,” Dr. Carter said. “When it’s the physician’s office, it works so much better because our physicians and disease management team have a much closer relationship with the patients.”
Texas experiments with ACOs Several other ACO experiments with different structures and payment mechanisms are under way in Texas. The Seton Health Alliance is a Pioneer Medicare ACO. Phy- sicians are paid initially under a shared-savings-and-losses ar- rangement based on performance benchmarks and later under a population-based payment model of set monthly, per-benefi- ciary payments, or other approved alternatives. Federal health reform regulations lay out specific param- eters for these ACOs that require, among other things:
July 2013 TEXAS MEDICINE 21
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