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.”
In addition, although ACOs focus on primary care, they are accountable for covering the entire cost of their patients’ healthcare, which includes surgery (but not drug costs). The study cites other research that shows that the average American has nine surgeries throughout his or her lifetime (J Am Coll Surg. 2008;207[3 Supp]:S75). Nationally, surgery represents approximately 50% of hospital expenditures and accounts for an estimated 30% of total healthcare costs (Ann Surg. 2010;251:195-200). “Even if ACOs are able to achieve their goals in chronic disease management, overlooking the role and cost of surgical care may negate those savings,” the study authors stated.
Benefits Seem Small
Surgeons can voluntarily join ACOs, and how it’s done varies by the market. “They may sign a formal participation agreement, or it could be an informal agreement where the ACO agrees to include them in their referral network in exchange for their commitments to following the ACO’s objectives,” Dr. Weissman said.
But by not joining ACOs, otolaryngologists don’t seem to be missing out on too much—at least not at the moment. “ACOs are very much primary care focused; the present quality measures are all in this realm and have little to do with otolaryngology practice,” said Lee D. Eisenberg, MD, MPH, partner at ENT and Allergy Associates, LLP, in Englewood, N.J. “Until we are more integrated into ACOs and the measures are more relevant to our practice, we have little to gain as most of the shared savings are likely to be given to primary care physicians.” He added that this standard is appropriate at present because these physicians carry most of the risk for reducing expenses.
Dr. Eisenberg continued, saying, “I am not sure that we will ever benefit from cost savings, because our component of cost is minimal compared with other surgical specialties with a much higher Medicare population as part of their practice, such as urology and ophthalmology, or those with high-cost surgical procedures in the Medicare population, such as orthopedics.”
Dr. Weissman agreed. “I think the shared savings incentive will not be enough, because by doing just one extra procedure, surgeons can probably earn more money than the shared savings they may be eligible for,” he said.
On the positive side, Dr. Eisenberg believes that otolaryngologists might be able to benefit from increased referrals, their main means of garnering patients.
As far as patients are concerned, Dr. Eisenberg doubts that otolaryngologists’ nonparticipation in ACOs will significantly affect patients’ ability to obtain otolaryngology-head and neck services. “A patient may be assigned to an ACO, but that does not limit his or her choice of otolaryngologist and the present referral patterns will persist,” he said, adding that not participating in an ACO has had little effect on his practice thus far.
But, if at some time in the future otolaryngologists join an ACO, then there may be internal pressure to refer within the ACO for specialty care. “This could potentially affect patient care by limiting physician options for the patient,” Dr. Eisenberg said.
Benefits depend on whether or not you’re the only specialist in town, Dr. Dupree said. If you’re the only specialist, he doesn’t think the ACO will greatly impact your practice, because most likely all of these patients already go to your practice. “But if you are in a subspecialty competitive market, participating in an ACO may give you better access to patients,” he said.
If ACOs are moving toward surgical quality metrics, then it would be wise for surgeons to have a voice. Surgeons offer a unique and important perspective on how we can improve healthcare for patients.
—James Dupree, MD, MPH
Changes on the Horizon
Looking ahead, the study researchers believe that ACOs will mature and begin to pay attention to larger cost centers when they examine their expenditures and realize how much they’re spending on surgical care. “I also think that CMS may develop more quality metrics that affect surgery,” Dr. Weissman said.
This will be a good thing, he added, because patient care provided by primary care (the referral base) and surgeons needs to be better integrated to ensure that patient voices are heard, to make the referral process more efficient, and to make sure that only appropriate patients are referred to surgeons.
At some point, Dr. Nielsen said, ACOs will look beyond primary care, because “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.”
If ACOs do expand and surgical care examined more closely by the governance, then Dr. Dupree believes surgeons will need or want to participate in ACOs in order to gain access to those patients. In addition, “surgeons might want to brand themselves as being part of an ACO as a reflection of quality to attract patients,” he added.
As ACOs continue to grow and prosper, Dr. Coppola believes that an otolaryngologist who wants to control his or her destiny and make decisions about the most cost-effective way to provide care and get paid better for doing that will want to be involved in ACOs. But this will vary significantly between regions.
As an associate clinical professor of medicine at Tufts University School of Medicine in Boston, Dr. Coppola was involved in an ACO for five years. “It was not unusual for an ACO to look at otitis media in the pediatric population and gather a panel of pediatricians, primary care providers, and otolaryngologists to come up with a consensus agreement as to how that organization will deal with guidelines for otitis,” he said. For instance, would it require antibiotics, or would the patient require an ear, nose, and throat evaluation?
“But, in many communities, this hasn’t happened yet,” Dr. Coppola added. “In most of the United States, ACOs are still in the very early planning stages. In the future, short of a one-payer system, I think this model will show that if we give financial responsibility to the caregivers, we will wind up having a better healthcare delivery system for providers and patients.”
The bottom line, said Dr. Nielsen, is that otolaryngologists are not homogeneous. “Just because an ACO is not a feasible option for me doesn’t mean it isn’t a great option for another. Plus, at this point, there isn’t enough feedback about specialty care within ACOs to determine the impact.”
Karen Appold is a freelance medical writer based in Pennsylvania.