by Patricia Salber

The accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one.”  Mark Smith M.D., M.B.A., president and CEO of the California Healthcare Foundation

Pat Salber

Patricia Salber, MD, MBA, Principal Zia Healthcare Consulting

The reference to ACOs as unicorns is undoubtedly one of the most often repeated one liners in all of health policy speak. It conveyed that ACOs were a great dream, but were not (and in some people’s minds) would never be, a reality.

In 2010,  I attended one of the first National Accountable Care Organization Congresses held in Los Angeles.   There were lots of people and lots of enthusiasm, but not much in the way of concrete examples of what one of these mystical new delivery systems would look like or accomplish.  Fast forward to June 7-8, 2012 and I am once again attending a big ACO meeting, this time the Third National Accountable Care Organization Summit  in Washington DC.  What a difference!

We now not only can talk about real, and not mythical, ACOs.  But, as Elliott Fisher, one of the “Fathers of ACOs,” told the audience, there are hundreds of ACOs with signed contracts across the US – with clusters in the Northeast, Southern California, and Florida.  Former Governor Mike Leavitt said, interestingly, most of these ACOs are in the private, not in the public (e.g., Medicare) sector.  Not only are these organizations “real,” we are starting to see results.  Fisher reported that the Blue Shield of California/Hill Physicians ACO has saved $20 million – $5 million more than goal.  And, Susan Dentzer, Editor of Health Affairs, summed it up nicely by saying, “300 ACOS are now up and running, they are no longer unicorns.”

The most sophisticated and farthest along of the ACOs are the group of 32 Medicare ACOs known as the Pioneer ACOs.  Representatives from these ACOs shared some of their experiences with us.  Panelists included Caroline Blaum, MD, MS, Professor of Internal Medicine and Geriatrics, Assistant Dean for Clinical Affairs; Associate Director Faculty Group Practice, University of Michigan Medical School, Ann Arbor, Mi; Jonathan Blum, MMP, Deputy Administrator and Director of the Center for Medicare, Centers for Medicare & Medicaid Services ; Richard Merkin MD, President and CEO, Heritage California ACO, Northridge, CA; and Judy Rich RN, President and CEO, Tucson Medical Center in Arizona.

These panelists made the point that building and running an ACO is not for the faint of heart.  You do it, as Dr. Merkin said,  because “you want to change the world.”  The challenges are many and they are big:

  • Misaligned incentives (how do you keep your hospitals engaged when their admissions are going down?)
  • Getting and sharing data (good data, the right data)
  • Retaining patients who have choice – there are no lock-ins in ACO-land
  •  Engaging patients, particularly those with chronic illness, in new and more meaningful ways.

As Jonathan Blum from CMS put it “organizations won’t succeed working on the margins–care has to be fundamentally different.”  When asked what her biggest challenge was, Caroline Blaum from the University of Michigan said it best, “My biggest challenge is that there are too many challenges.”  And Judy Rich, RN from Tuscon Med Ctr reminded us that “Pioneers take the arrows, settlers take the land.”

The next panel was called “Moving Toward Accountable Care in States.  Panelists included Melanie Bella, MBA, Director of the Federal Coordinated Health Care Office, Centers for Medicare and Medicaid Services, US Department of Health and Human Services; Jeffrey Brenner MD, Director, Institute for Urban Health, Cooper University Hospital; Executive Director, Camden Coalition of Healthcare Providers, Camden, NJ; Bruce D. Greenstein, MS, Secretary, Louisiana Department of Health and Hospitals; Former Associate Regional Administrator and Director of Waivers and Demonstrations, Centers for Medicare and Medicaid Services, Baton Rouge, LA; and Julian Harris, MD, MBA, Medicaid Director, Massachusetts Department of Health and Human Services, Boston, MA.  Mark McClellan MD, PhD (also an ACO Father) was the moderator.

In his opening remarks, Dr. McClellan told us that Medicaid ACOs are going to be just as important as Medicare ACOs in “bending the cost curve.”  In fact, Melanie Bella said that CMS taking new, unparalleled steps to improve care for dual eligibles through increased accountability.  Jeff Brenner (one of Atul Gawaande’s Hot Spotters) and Executive Director, Camden Coalition of Healthcare Providers said he wants to mine the waste in healthcare to fund the work that needs to be done.  And he talked of challenging NJ officials to adopt reforms that create better, higher value care (as I said this work is not for wimps).  He said spending time talking about whether care coordination works or not “is stupid,” – it is  better to spend time figuring out who who will respond to the intervention.  He continued, saying, “The best thing we’ve done is to send care coodination staff to the hospital and to the first post-discharge visit.”  These folks make sure information about the hospitalization is collected and organized for the primary care doctor with the result that the post-discharge visit is faster and better.

I finished the morning full of hope that ACOs could be an important vehicle for the type of healthcare transformation that I have hoped would happen in my lifetime.  Yeah, I know, we still have the SCOTUS decision looming in front of us (one newscaster, Candy Crowley opined that we could get the opinion as early as tomorrow).  But even if the Supremes nix the individual mandate or (heaven forbid) throw out the entire health reform legislation, the fact that the private sector is embracing accountable care makes me think these unicorns can continue to grow, develop and hopefully flourish as a viable alternative to our current volume based, unaccountable healthcare “system.”