Otolaryngologists Missing from Leadership Ranks of Accountable Care Organizations

Although physicians play a significant role in governing the first private and public accountable care organizations (ACOs), few surgeons are participating, according to the results of a new study published in Health Affairs and funded by a grant from the American College of Surgeons (Health Affairs. 2014;33:972-979). Further, otolaryngologists have not been a primary target among those surgeons who have been asked to join.

“The bodies that manage ACOs are usually looking to include the biggest ticket items—such as emergency room visits, controlling inpatient utilization, and pharmacy costs,” said Michael Coppola, MD, executive vice president of medical affairs and chief medical officer at NovaSom, Inc., a Glen Burnie, Md.-based company that develops home testing and evaluation for obstructive sleep apnea. “And, of those entities, specialties that are targeted revolve around cardiovascular disease, diabetes, and asthma. So otolaryngologists just aren’t on the bucket list as the first order of business.”

This is because the greatest return on an effort to reduce costs while improving quality in healthcare reform is to focus more on effective management of care for chronic conditions, avoidable and unplanned hospital admissions, and preventive care, which are more addressable by primary care and more expensive than surgical care, said David R. Nielsen, MD, executive vice president and CEO of the American Academy of Otolaryngology–Head and Neck Surgery.

ACOs, a payment model authorized by the Affordable Care Act and approved by the Centers for Medicare and Medicaid Services (CMS), are composed of physicians, hospitals, and other care providers who collaborate to offer integrated and more seamless care to patients. They strive to give incentives for reducing costs and improving quality, while not limiting a patient’s options.

Surgeons on the Outskirts

The researchers involved in the Health Affairs study said that surgeons’ lack of involvement with ACOs is not surprising, due to the fact that none of the 33 ACO quality measures put forth by CMS directly address surgery or surgical care. ACOs can earn financial bonuses if they save money against predetermined benchmarks and improve quality under Medicare’s accountable care program.

In addition, surgeons were not on the executive committee of two of the four ACOs. In fact, in surveying early Medicare ACOs, the researchers found that 14 of 28 respondents didn’t have any surgeons serving on their executive committees.

The researchers say it would be wise for ACOs to include surgical care in their strategic priorities. “If ACOs are moving toward surgical quality metrics, then it would be wise for surgeons to have a voice,” said James Dupree, MD, MPH, assistant professor in the department of urology at the University of Michigan, Ann Arbor, and co-author of the study. “Surgeons offer a unique and important perspective on how we can improve healthcare for patients.”

Primary care can’t do this all on its own. The help of specialists will be needed in order to continue the momentum for improvements to the healthcare system.
—David Nielsen, MD

Joel S. Weissman, PhD, associate professor of health policy at Harvard Medical School, deputy director and chief scientific officer at the Center for Surgery and Public Health at Brigham and Women’s Hospital/Harvard Medical School in Boston, and a co-author of the study, agreed. “The cost of surgery is a large component of the Medicare population’s spending patterns and it’s also an area that can be improved from both a quality perspective and cost perspective,” he said. “There are many surgeries that could be avoided with better planning and more patient input. There is a lot of room for improvement.”