Accountable Care: Should You Care?

Last year’s landmark health-care reform law — the Patient Protection and Affordable Care Act — has gotten renewed attention in recent weeks, as the House of Representatives voted to repeal it and the Senate is expected to vote on (but reject) its repeal as well. One provision of the law that has recently come under focus is its establishment of Accountable Care Organizations (ACO’s), which are set to come into existence in early 2012 and have been hailed by some as way to reduce health-care costs while improving patient outcomes.


As a recent article from NPR explains, under the framework set forth in the health-care law, ACO’s will consist of doctors and hospitals that voluntarily form a network to take responsibility for the care of Medicare patients. Patients would not, however, be forced to stay within this network for their health-care needs. The ACO would then be given financial incentives, through Medicare, to keep the cost of care down, as well as to keep the quality of care high as measured by medical outcomes. (Medicare will publish regulations for ACO’s later this year.) The purpose of this setup is to foster efficient, cooperative care focused on results — unlike, in the view of many, the current fee-for-service Medicare reimbursement scheme, which simply pays doctors for each visit, test, or procedure that a patient receives.

A potential pitfall of this system is that patients could seek out care outside of their ACO, thus possibly generating extra expenses that undermine the ACO’s overall cost-effectiveness. Each ACO would most likely come up with incentives for patients to see its own providers, since its own incentives from Medicare will depend, in part, on limiting the overall cost of care for a patient — even if that care comes from outside the ACO. As Dr. Pauline W. Chen points out in The New York Times, the success of ACO’s could therefore depend very much on whether patients buy into the concept, or at least whether they follow the incentives that their ACO offers.

And, of course, ACO’s have to expect some degree of success in limiting patients’ expenses in order to exist in the first place. The future of ACO’s could thus depend on the early performance of the first ones: If they are successful at keeping costs down, more would surely spring up, and the payment model could spread through Medicare and to private insurers. If early ACO’s falter, the new system could quickly dissolve.

Do ACO’s sound promising to you, or potentially unworkable? Would the prospect of cost savings within the broader health-care system be enough to motivate you to cooperate with an ACO? Would you be likely to respond to its financial incentives, or would even these be unlikely to stop you from seeing an outside doctor or hospital if you wanted to? Leave a comment below!

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  • Andy Wolff

    The use of “incentives” for any purpose is self-defeating. If a patient doesn’t like the treating physician and wishes to go elsewhere, he is penalized, in effect. What will the doc do, split the incentive with the patient if he/she stays silent?
    This is like trying to guarantee better education by raising teacher salaries. What is better? Who judges? Is it the medical equivalent of “teaching to the test,” i.e. “treating according to guidelines?”

    There are general problems in Medicine that need to be aired, if I may:
    In my case, I was hit by a bicycle rider a few years back and the pains I have are on that side. The doctor I saw recently says I have early arthritis. It feels different, but he’s the only orthopod in the hospital I use. What is the incentive argument relevancy here?

    There is no question medicine in general costs too much. Putting it all under governmental control is clearly no solution (any more than privatizing “Public Utilities ” was. The only realistic solution is to do what the Japanese did in the auto industry, and that we have begun to emulate; to wit, Cooperative Worker Circles. The version I have in mind allows anonymous workers to feed a suggestion box for their own circle. This is a manageable group. It is analogous to neighborhood groups engaged in community action. No one need take reponsibility for what is out of anyone’s control: there is no taxation without representation.
    The results of this kind of internal control are manageable and word-of-mouth susceptible. We all know what that means in the time of the blog. No incentive is better than pride.

    Here are Medicine’s problems in a nutshell:
    1) A second doc is liable to agree with the first out of professional courtesy. No help, there;
    2) Alternatively, if the second doc is mainly in Internal Medicine, he’ll prescribe drugs. If he’s a surgeon, he’ll want to cut, etc.
    3) In any operation, one has no control over who actually does the work. Doctors uniformly are of forked tongue, depending on whether they want to play golf that day;
    4) The anaesthesiologists have their own shop as shamans-for-hire, bill separately and are completely out of anyone’s control or supervision.
    To refine the last comments, individual doctors tout how only they can do the job right, unless of course they botch it, in which case they try to transfer responsibility.
    “Complications” are actually the leading cause of death.
    Of course, as has been said forever, “What do they call the person who finished last-in-class at medical school? Why, “Doctor,” of course.
    Every year, some media outlet or other is paid to publish a list of the “50 Best Doctors,” or hospitals, etc. These are regional, bear no resemblance to objective reality (impossible at best), and, like televised med stuff, canonize doctors (see last-in-class comment). Advertising meds to the public is also reprehensible (“Ask your doctor if (fill in the blank) is right for you.” They are all toxic to the liver, but I digress.

    There are workable solutions to Medicine’s problems, but the suggestions all address them in terms of financial cost. This “industry” is being bad-mouthed because of its financial leaders, not its in-the-field practioners. They have been subverted by the lure of financial gain. That is the problem, and that should be the target of those who would fix things.

  • Deb Dixon

    Would an ACO only be “drs and hospitals”? How about nurse practitioners?

  • Jane

    It’s a good concept. I’m familiar with the Geisinger organization in PA which is frequently cited as an example. I hope my doctor, hospital, etc. get together and form a group. I like the idea of consolidating care under an umbrella group so everybody knows who is doing what. I would like to hear the drawbacks if someone has some experience to cite.

  • Richard Spalding

    This is another case where the government knows what’s best for the general public and we, the people, will be dragged to the watering hole and forced to drink from the trough whether we want to or not. The most effect way to control the cost of health care is for the general public to know what their doctors visits, medication, x-rays and labs actually cost and then make a decision as do you really need another x-ray and etc.

    I plan to trust my doctor and have conversations with him as a medical and health care partner, not just a medical authority.

  • Berdine Schrader

    This sounds good. Currently my health insurance will pay for diabetes classes this is new. If these programs work they have to be available for everyone both city and rural. Would another part of this be an exercise program and again located in rural areas. Also another issue is the insulin pump. Would this make the insulin pump more available and covered by insurance more? My interest is peaked as I will go on medicare in July of this year. All of this seems to be related to helping the provider save money not helping the patient out of pocket expenses except better control means less complications.

  • Diane Fennell

    Hi Ms. Schrader,

    Thanks for your comment. Diabetes Self-Management has a variety of pieces on dealing with diabetes and gastroparesis. For starters, check out Amy Campbell’s threepart series, the article “Treating Gastroparesis,” and our gastroparesis definition.

    Thanks for your interest in Diabetes Self-Management!

    Diane Fennell
    Web Editor

  • jim snell

    Even before this “improvement is to start, I have watched my wife’s and my Medicare Advantage plan.

    I am now on basic medicare plus spplement plan and both our costs have doubled to what they were last year. Some help!

    As for medicare – need test diabetic test strips, they will pay for 4 a day for diabetics on insulin. Less for the pill only crowd. Doesn’t matter that average type 1 ser ses 10 to 16 strips a day ferriting out lows.

    CGM and test probes not covered.

    I have little faith in this mess concocted in closed rooms out of sight, non review and non approval of those of us who are impacted.

    My diabetes doctor who has been with me for last 10 years thru thick or thin cannot bill medicare due to some beaurocratic nonsense. Advantage plan last year had none of that crap.

    I looked for approved doctor under medicare in the 2 city blocks of doctors and hospital in my area and they had one doctor listed out of at least 60 doctors working in area.

    This plan is crap and should be repealed.

  • Susan

    Reminds me of the days of DRG’s an cost effective improved care medicine. A lot of hog wash, angry doctors and disappointed patients. I worked it. I was there and I am a patient.

  • Amaze02

    Here’s one possible alternate solution to government involvement in health care.
    I’m sure there are others.

    An approach to lowering health care cost is not, government intervention or take over, or bureaucratic oversight, but allowing each of us to spend our medical dollars with those providers that do a good job for us.

    1) The government could set up Health Saving Accounts, where, pre taxed money accumulates. If spent on Medical needs, no taxes paid, if spent for any other reasons it would be taxable. These monies would travel with you from job to job.

    Health Saving Accounts causes us to see what we spend, taking out the insurance companies
    Comparing who you spend your dollars with.
    Competition reduces the cost as it has with elective surgery.

    Taking the middleman (the insurance companies) out. Would cause us to see, directly, what we spend for our medical needs, and make decisions, as we do on any other service we buy.

    You watch and compare when you are spending your dollars directly.

    Competition will drive the cost down, just as it has, in all cases, of elective surgery. IE: cosmetic surgery, Lasik surgery etc. All not covered by insurance.

    The cost for these medical services have been dropping each year.

    Let free enterprise work.
    It always does!

  • bull frog

    I don’t think so. Engaging in the madness of free enterprise with a person’s health and well being is inherently immoral in a society. Got to be, given the nature of that beast. Free enterprise aims for one thing and one thing only as a measure of it’s succerss—profit. That’s fine when it comes to lawn mowers, the newest fashion, the latest high tech computer gadget, cell phones and the like, but, sorry, free enterprise, in my book, does not deserve any accolades when it comes to the health and well being of the members of the society. And that includes the “least amongst us”. Free enterprise always works? Is that why the United States of America ranks number one above all others in the demonstrated health of it’s citizens? Ya think? Look again- we are embarrassingly far down the ladder when it comes to that .

  • Carol Gable

    Something needs to be done to prevent duplicate testing. If a patient goes from one doctor to another or from one nursing home to another, the doctors all seem to want to order their own tests. Shouldn’t there be coordination between facilities and doctors to avoid duplicate testing.