A Cautious Path Forward on Accountable Care Organizations

Richman, Barak D.

doi:10.1001/jama.2011.111

Cited by 26 publications

(14 citation statements)

References 7 publications

(4 reference statements)

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“…(25, 85–87) However, it remains to be seen whether patients could serve as their own advocates, vis-à-vis ACOs who are growing in size and power. (16, 40, 41, 88) Further research is needed to understand patients’ perspectives and roles in this context, as well as efforts to make these issues visible to patients.…”

Section: Discussionmentioning

confidence: 99%

Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies

Trosman

Weldon

Douglas³

et al. 2017

Value in Health

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Background New payment and care organization approaches, such as the Accountable Care Organization (ACO), are reshaping accountability and shifting risk, as well as decision-making, from payers to providers, under the Triple Aim of health reform. The Triple Aim calls for improving experience of care, improving health of populations and reducing healthcare costs. In the era of accelerating scientific advancement of personalized medicine and other innovations, it is critical to understand how the transition to the ACO model impacts decision-making on adoption and utilization of innovative technologies. Methods We interviewed representatives from ten private payers and six provider institutions involved in implementing the ACO model (i.e. ACOs) to understand changes, challenges and facilitators of decision-making on medical innovations, including personalized medicine. We used the framework approach of qualitative research for study design and thematic analysis. Results We found that representatives from the participating payer companies and ACOs perceive similar challenges to ACOs’ decision-making in terms of achieving a balance between the components of the Triple Aim – improving care experience, improving population health and reducing costs. The challenges include the prevalence of cost over care quality considerations in ACOs’ decisions and ACOs’ insufficient analytical and technology assessment capacity to evaluate complex innovations such as personalized medicine. Decision-making facilitators included increased competition across ACOs and patients’ interest in personalized medicine. Conclusions As new payment models evolve, payers, ACOs and other stakeholders should address challenges and leverage opportunities to arm ACOs with robust, consistent, rigorous and transparent approaches to decision-making on medical innovations.

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Section: Discussionmentioning

confidence: 99%

Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies

Trosman

Weldon

Douglas³

et al. 2017

Value in Health

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“…A program that becomes skewed towards large ACOs raises a number of important policy concerns. Large ACOs may accumulate a great degree of monopoly power leading to higher prices and inefficient resource allocation in private markets (Richman & Schulman, 2011). Even in Medicare where prices are set nationally, ACOs that become too large could limit choices and care options available to patients.…”

Section: E10mentioning

confidence: 99%

Statistical Uncertainty in the Medicare Shared Savings Program

DeLia¹,

Hoover²,

Cantor³

2013

MMRR

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Objective: Analyze statistical risks facing CMS and Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP). Methods:We calculate the probability that shared savings formulas lead to inappropriate payment, payment denial, and/or financial penalties, assuming that ACOs generate real savings in Medicare spending ranging from 0-10%. We also calculate expected payments from CMS to ACOs under these scenarios. Results:The probability of an incorrect outcome is heavily dependent on ACO enrollment size. For example, in the MSSP two-sided model, an ACO with 5,000 enrollees that keeps spending constant faces a 0.24 probability of being inappropriately rewarded for savings and a 0.26 probability of paying an undeserved penalty for increased spending. For an ACO with 50,000 enrollees, both of these probabilities of incorrect outcomes are equal to 0.02. The probability of inappropriate payment denial declines as real ACO savings increase. Still, for ACOs with 5,000 patients, the probability of denial is at least 0.15 even when true savings are 5-7%. Depending on ACO size and the real ACO savings rate, expected ACO payments vary from $115,000 to $35.3 million. Discussion: Our analysis indicates there may be greater statistical uncertainty in the MSSP than previously recognized. CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning. We also suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as efficiently as possible.

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“…IPAs perform various functions on behalf of medical practices including contract negotiations with insurance companies, credentialing and inspection of member doctors, institutions and services and disbursement of payment to doctors. Furthermore, the Affordable Care Act of 2010 encourages the growth of Accountable Care Organizations, which create incentives for healthcare providers to work together, and links rewards to cost reduction and the achievement of quality targets (Richman and Schulman, 2011).…”

Section: Introductionmentioning

confidence: 99%

Restratification revisited: The changing landscape of primary medical care in England and California

McDonald

2012

Current Sociology

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Restratification, a process which involves medical elites exerting control over members of their profession, was seen by the US sociologist Eliot Freidson as helping to maintain the continued dominance of the medical model and the profession's ability to determine its own fate. Drawing on interviews with primary care doctors in England and California this article reports the emergence of new strata or elites, with groups of doctors involved in both surveillance of others and action to improve compliance in deficient individuals and organizations. The article compares responses of primary care doctors to these developments and explores the implications in the context of Freidson's predictions.

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A Cautious Path Forward on Accountable Care Organizations

Cited by 26 publications

References 7 publications

Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies

Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies

Statistical Uncertainty in the Medicare Shared Savings Program

Restratification revisited: The changing landscape of primary medical care in England and California

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