A new study published in Health Affairs argues much of the analysis of accountable care organizations has neglected a crucial question: Who are the doctors participating in them?
Focusing on one ACO in the Medicare Pioneer program, a team of academic researchers discovered a high rate of turnover, a trend they argued likely undermined the intended effect of the coordinated care model.
Forty-one percent of the doctors that were part of the ACO during the two-year period examined joined during that time. Another 18 percent left during the period.
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About half of the patients in the ACO were simply part of it because their physician began affiliating with the ACO. Similarly, when doctors left the organization, most of their patients left with them.
Perhaps most significantly, the study found doctors who are affiliated with ACOs only have a small percentage of their patients (an average of 5 percent) through the care model. As a result, the outcome-driven accountability measures the doctors are submitting to through the ACO unlikely has a big impact on their bottom line.
The researchers also argued that doctors are unlikely to fundamentally change their behavior in response to a system that only relates to one out of 20 of their patients.
In addition, the risk profile of the average patient appeared to be relatively low, the study found. Most doctors were not responsible for many very sick patients, suggesting the ACO could be selecting for healthier patients to achieve better performance metrics.
"These findings may help explain the muted financial impact ACOs have had overall, and they raise the possibility of future gaming on the part of ACOs to artificially control spending," write the study authors.
The skepticism of ACOs expressed in the study is clearly shared by many physicians, as demonstrated by a separate survey of ACO participants that was also published in Health Affairs.
Just over half of the doctors who participated in the Pioneer program agree the ACO model is effective for the "provision of high-quality care." A similar percentage agreed the model was effective at containing or reducing costs.
Physicians who participate in Medicare Shared Savings Program, another ACO program, gave their model slightly better marks.
However, a much larger percentage of those who participated in a third Medicare ACO, the Advanced Payment system, say the model was producing in terms of quality and cost.
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