By Donald W. Rucker, MD, MS,
MBA
At
their core, accountable care organizations (ACOs) are legal entities comprised
of primary care physicians (PCPs) or other primary care providers and the pool
of their Medicare patients (which number at least 5,000). Other providers and
hospitals may participate, but the PCPs must run the show (although they can be
employed).
Patients
are enrolled automatically, and while they can choose to receive care anywhere,
the cost of that care – regardless of the site(s) providing it – is attributed
to the pool of PCPs who share in a percentage of any savings in the treatment
of those patients. That pool of PCPs also may share in any losses – either
immediately or years later. If that happens, the PCPs must pay back their
income to CMS.
The
practice of bundled payments – paying physicians and hospitals by the procedure
– is ground zero of the delivery and payment reform debate in the United
States, with ACOs being the most recent example of bundling payment. Economic
risk is the glue for bundling – it incentivizes providers to use less of their
own services (or those of other providers), such as computed tomography (CT) and
magnetic resonance (MR) scans, office visits, surgeries, and hospitalizations.
One might expect patients to be at equal risk of providers doing too much if
they’re paid via fee for service versus doing too little if physician payments
are capitated. However, current discussions regarding bundled payment policy
implicitly assume that our health care system has such an “overtreatment” bias
that we need not worry about under-treatment for some time. We also assume,
secondarily, that consumers have enough current options to prompt them to seek
treatment elsewhere if skimping becomes an issue.
How
could physicians generate savings via ACOs – and how do patients benefit? And
how will the “sharing” of savings or losses among PCPs be calculated? I’ll
address those questions in next week’s blog.
Professional
biography:
Donald W. Rucker, MD,
MS, MBA, is vice president and chief medical officer of Siemens Healthcare USA,
the healthcare division of Siemens. A graduate of Harvard College and the
University of Pennsylvania School of Medicine with Board Certifications in
Internal Medicine and Emergency Medicine, Dr. Rucker holds a master’s degree in
Medical Computer Science and an MBA, both from Stanford. Dr. Rucker came to
Siemens from Boston’s Beth Israel Deaconess Medical Center, where he was the
first full-time Emergency Department attending, and from Datamedic Corp., where
he co-developed the first Microsoft Windows based electronic medical record.
Dr. Rucker recently completed two terms on the Board of Commissioners of the
Certification Commission for Healthcare Information Technology. He also
practices emergency medicine in the University of Pennsylvania Health System.