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Circulation. Author manuscript; available in PMC 2016 August 15. Published in final edited form as: Circulation. 2015 August 18; 132(7): 603–610. doi:10.1161/CIRCULATIONAHA.114.010269.
Accountable Care Organizations: Ensuring Focus on Cardiovascular Health Kavita K. Patel, MD, MSHS1, Joaquin E. Cigarroa, MD2, Jeffrey Nadel, BA1, Deborah J. Cohen, PhD3, and Eric C. Stecker, MD, MPH2 1Engleberg
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2Knight
Center for Health Care Reform, The Brookings Institution, Washington, D.C.
Cardiovascular Institute, Oregon Health & Science University, Portland, OR
3Department
of Family Medicine, Oregon Health & Science University, Portland, OR
Keywords Healthcare policy; Healthcare costs; health care
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While unparalleled in the provision of intensive lifesaving treatments, US health care has only begun to focus on other important aspects of population health. In order to achieve the triple aim of better health, better care and lower costs, payment and delivery systems must evolve. The accountable care movement is central to this evolution, and engagement by cardiovascular specialists can help to shape it. Sustained partnering with policymakers could improve patient care by appropriately directing cardiovascular medicine resources and avoiding unintended harm to well-functioning systems of care.
Accountable Care Organizations
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Accountable Care Organizations (ACOs) are part of a new payment and delivery model that aims to improve quality of care while controlling costs for populations of patients.1, 2 ACOs took conceptual shape nearly ten years ago as an approach to achieve these goals in a manner that fosters flexibility.3, 4 Unlike the managed care movement in the 1990s, capitated payments have not been a foundational element of the ACO movement (though components of capitation will likely prove important5). ACOs were therefore less disruptive to the status quo ante, and with inclusion in the Affordable Care Act of 2010 they gained considerable momentum. While Medicare has specific requirements for ACO structure and patient attribution, state and private insurers have engaged in a variety of alternative ACO models that could drive innovation. Within ACOs, providers can be configured in a number of ways ranging from physician-led groups and integrated delivery systems to hospital-based systems coupled with independent practice associations.2–4, 6 The adoption of electronic health
Correspondence: Eric C. Stecker, Knight Cardiovascular Institute, Oregon Health & Science University, UHN-62, 3181 SW Sam Jackson Park Road, Portland Oregon 97239; phone 503-494-7400; fax 503-494-8550; [email protected]. Disclosures Drs. Stecker and Cigarroa receive salaries with fee-for-service-based incentives and productivity tracking.
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records has been an important feature that allows ACOs to measure and integrate care for populations of patients. Regardless of structure, it is widely accepted that ACOs should: 1) be provider-led and accountable for the entire continuum of care for a population, 2) have payments structured to incentivize lower-cost, higher quality care, and 3) engage in reliable performance measurement techniques that instill confidence in the quality of care provided.2, 5 Although early forms of ACOs have focused on primary care, meaningful inclusion of specialists will be required for long-term success.7–9
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The payment model for ACOs can take several forms. Fundamentally, providers agree to be accountable for the quality of care and total cost for a population based on prior benchmark years of expenditures.6 If quality thresholds are met and the ACO saves money over the year, the savings are shared between the ACO and payer. These shared savings arrangements are the foundation of the payment model and serve as the primary incentive to practice high value health care.10 In theory, fully mature ACOs would eventually take on financial risk and achieve partial or full capitation so that payments are independent of the volume and intensity of services provided.2, 3, 11 To date, however, the majority of ACOs operate in a primarily fee-for-service environment with shared savings.
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ACOs have flourished in both the public and private sector. All major payers are engaged in accountable care contracts, including the Centers for Medicare and Medicaid Services’ (CMS) Pioneer ACO Program and Medicare Shared Savings Program. By the end of 2013, more than 600 public and private ACOs were in operation, including 366 Medicare ACOs.12 Although ACOs hold promise for curbing costs and improving quality, it is too early to tell whether they are an effective and complete solution to the systemic problems in health care.13, 14 Nonetheless early results indicate modest savings are achievable. CMS’ Pioneer ACO program showed an estimated net savings of $118 million ($29 per member per month) among 32 ACOs providing care for 566,000 Medicare beneficiaries.15 Despite these overall savings, more than half of participating organizations dropped out of the Pioneer ACO program, and continued participation was not predicted by estimated ACO savings. These results imply that greater shared savings as well as modifications to benchmarking may be required to successfully disseminate a Medicare ACO model. An example of a commercial ACO is provided by the Sacramento CalPERs ACO, established in California in 2010 by a physician group (Hill Physicians Medical Group), insurer (Blue Shield of California), purchaser (CalPERS), and hospital system (Dignity Health).16 This organization provides care for 41,000 enrollees and uses a hybrid of share savings/risk, global payments and fee for service.17, 18 The provider-payer relationship is governed in a way that allows for modular integration of additional ACOs and continuous innovation and improvement of delivery methods (Figure). The Sacramento CalPERS ACO alone has generated savings of $95 million in addition to distributing $10 million in shared savings to provider organizations while improving quality performance metrics.16 Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract program provides an example of a successful statewide program. Using modified global payment / quality contracting arrangements with ACO-like organizations, this program produced a 1.9% savings while improving quality metrics in its first year.19 Although ACO programs focused on state Medicaid populations
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have been established in Colorado, Maine, Minnesota, New Jersey, Oregon and Vermont,20 it is premature to assess their impact on quality and cost.
Cardiovascular Medicine and Accountable Care
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Cardiovascular medicine, an increasingly important focus in the accountable care movement, makes up the largest portion of health care costs.21, 22 Spending related to cardiovascular disease is projected to reach $1.5 trillion, by 203023 and it remains the leading cause of death and disability in the US.24 During the last 20 years, major improvements in the provision of evidence-based care, including both preventive and catastrophic care, have led to significant reductions in morbidity and mortality.25–27 However, there has been little attention to societal cost efficiencies when designing new systems of care. A change in payment structure, better care coordination, augmented data, and improved care management—hallmarks of accountable care—could enable improvements in health and more efficient use of cardiology expenditures.
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Despite the high burden and cost of disease, defining where cardiology fits into accountable care models has been difficult. To date, ACO models have primarily engaged primary care providers and are just now starting to incorporate specialists and specialty care.8 One example, Oregon’s Coordinated Care Organization (CCO) model, has yielded encouraging preliminary results. CCOs were established in 2012 and are collaborative networks of health care providers—both in primary and specialty care—caring for patients covered under the Oregon Medicaid plan. The combination of a CCO focus on decreasing all-cause hospitalizations and an independent focus by hospitals and cardiology service lines on decreasing heart failure readmissions (due to Medicare payment reforms) has led to a 27% reduction in overall hospitalizations for congestive heart failure.28 Further, Florida Blue Cross Blue Shield has launched a number of commercial ACO contracts with the goal of controlling high-cost areas such as cardiovascular medicine by focusing on heart failure and including cardiologist in shared savings arrangements.29
Supporting Cardiology Quality Improvement within ACOs
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Professional organizations can assist in the successful implementation of ACOs by providing access to registries, supporting organizational learning communities, incorporating accountable care into graduate medical education and continuing medical education, and creating tools for clinical practice that maximize appropriate care. Such support and resources can simplify the challenge of adopting effective systems of care and improving outcomes. For example, the ACC’s National Cardiovascular Data Registry (NCDR) and the American Heart Association’s (AHA) Get With the Guidelines (GWTG) registries constitute a collection of nine hospital-based registries and two outpatient registries. NCDR alone includes over 2,400 hospitals and approximately 1,000 outpatient providers.30 These registries provide benchmarked process and outcome data with greater detail and timeliness (and therefore actionability) than the claims-based information provided by payers. Employing appropriate use criteria to evaluate practice- and hospital-level patterns of cardiovascular care also has the potential to improve quality and control costs. Appropriate
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use criteria define evidence-based, professional-consensus-driven standards for using tests and therapies. These criteria serve as adjuncts to practice guidelines by highlighting common or controversial clinical scenarios that may require nuance beyond that readily available from the primary analysis of randomized clinical trials. Although there is a focus on overuse, these tools can also allow assessment for underuse of high-value clinical services. The methodology, developed in a collaboration between RAND and UCLA, has several important features: a standardized development approach; an unbiased literature review as the basis for evaluation; clinician input regarding the most important clinical scenarios to be evaluated; and at least two rounds of review by a panel of content experts (first round alone, second round as a group to work toward consensus).31
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Participating in national collaborative programs with peer organizations could also accelerate the quality improvement measures that are critical to the accountable care movement. The ACC and AHA have undertaken major national initiatives to create learning communities for health systems and providers to facilitate organization-level improvement in cardiology. For example, a program focusing on strategies to improve door-to-balloon time for ST-elevation myocardial infarctions (originally named D2B Alliance, now D2B:Sustain the Gain32) has led to marked organizational changes in participating health systems.25 Expanded use of such programs could help ACOs improve the overall effectiveness and efficiency of cardiovascular care.
Potential Challenges
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Despite the promise of ACOs, effective integration of specialists is unproven and faces challenges. For example, a study evaluating patterns of use of discretionary cardiovascular imaging and procedures in a Medicare pilot ACO program (the Physician Group Practice Demonstration program; PGDP) showed no impact on utilization.33 While there are inherent methodological limitations (difference-in-difference rather than randomized analysis, claims-based rather than registry-based variables), this study indicates that policies meant to alter specialty care patterns can be contravened by a variety of potential factors including fee-for-service payments, magnitude / alignment of financial incentives, degree of focus on specialty care, and overall heterogeneity in accountable care systems.
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A fundamental challenge is that specialists engage in the care of patients in a different manner than generalists. Unlike primary care providers, most surgical specialists and many cardiologists (e.g., electrophysiologists, interventionalists) engage in patients’ care for a limited time with a narrow scope. Some cardiologists may practice in a hybrid model in which they assume long-term responsibility for some disorders (e.g., severe heart failure) and episodic responsibility for others (e.g., ischemic heart disease, arrhythmias). Cardiologists, emergency medicine physicians, and others also routinely engage in complex systems of care that are time dependent such as ST-elevation myocardial infarction (MI) and cardiac arrest treatment. Conventional ACO designs may not adequately address quality considerations in this hyperacute phase of the continuum of care.7 Together these challenges add considerable complexity to the task of appropriately attributing quality, outcomes, costs and incentives for ACO specialty care.
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Measuring the health benefits attributable to specialty care is also complex. For example, while few medical procedures have more direct impact on morbidity and mortality than prompt reperfusion for ST-elevation MI, its benefits can be challenging to describe at the population level. One large study analyzing mortality after ST-elevation MI showed no improvement, despite dramatic improvements in door-to-balloon times.34 Inferences that this reflects a lack of primary percutaneous coronary intervention efficacy are tempting but may be inaccurate (potentially an ecological fallacy due to increasing risk among procedural patients over time). Overall, comparisons of outcomes must carefully control for different levels of clinical risk at both patient and population levels. The debate over using socioeconomics in risk adjustment for hospital readmissions35–37 illustrates the complexities entailed when comparing and incentivizing population-based quality measures in heterogeneous contexts. Given the many factors that influence health, it can be difficult to define the scope of health care providers’ responsibility for health outcomes.
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There are inherent statistical limitations to measuring quality outcomes at the level of small health systems and most physician groups. In the past there has been focus on risk adjustment, but statistical noise often overwhelms signal even for risk-adjusted measures if denominators are small. In fact, an analysis commissioned by CMS showed that fewer than half of US hospitals had sufficient patient volume to achieve moderate statistical reliability over 24 months of data accrual for 30-day risk-adjusted mortality and readmission rates.38 Similarly, few hospitals have sufficient volume to use surgical mortality as a statistically reliable indicator of quality for most types of operations.39
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Even if measurement methods are accurate, aligning quality with profits is challenging and can introduce ethical concerns. As alluring as it has been for health systems to build highcost cardiology infrastructures to maximize market share and revenue under fee-for-service payment systems, it may be equally alluring to aggressively scale back cardiology costs if capitation arrangements become the dominant payment method. Creating robust quality measurement systems that are overseen by the critical stakeholders (including patients, primary care providers, cardiovascular specialists, and administrators) will minimize the risk of inappropriate use or withholding of cardiovascular care in ACOs. Current quality measurement and governance structures are not yet mature. For example, cardiologyrelevant performance metrics for Medicare ACOs40 (table 1) do not evaluate outcomes for patients with cardiovascular disease; and many ACOs governance structures appear to have limited representation by patients and specialists.
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The coexistence of fee-for-service and global payments during transition periods may limit the ability of cardiologists and ACOs to adopt efficient and effective systems of care. In a predominantly capitated system, the primary trade-off to consider when improving the efficiency of medical care is whether quality will be adversely impacted. In a mixed payment environment, the tradeoffs become more complex. Improvements in efficiency could decrease revenue under fee for service such that they undermine reform efforts.13 Constructing effective payment and delivery models for rural and socially disadvantaged populations is also challenging. Medicare ACOs operate in 43% of metropolitan counties and only 17% of non-metropolitan counties.41 Anticipating the lower capital reserves of
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rural organizations, CMS has created an “advanced payment option.” Qualifying ACOs receive upfront payments to help fund start-up infrastructure and personnel that will lead to later savings.42 Disadvantaged populations have similar challenges in attracting wellcapitalized health care organizations and could also benefit from advanced payments.43 Despite such challenges, both rural and disadvantaged populations could greatly benefit from a shift to ACOs if funding and organizational obstacles can be overcome.
Potential Solutions
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Regardless of payment model (fee-for-service, capitated or mixed), maximizing the cardiovascular health of ACO populations will aided by more sophisticated quality measures. Existing performance metrics40, 44, 45 (tables 1, 2 and 3) are dominated by process measures and admission/readmission measures. However, these metrics encompass only a small portion of well-functioning systems of care and are unproven surrogates for mortality, important patient-reported outcomes and patient experience.46, 47 In addition, the value of well-functioning systems for hyperacute conditions such as ST-elevation MI, out-of-hospital cardiac arrest and stroke must be measured and appropriately incentivized. While the requirement for addressing the entire spectrum of care precludes suggestions to create acutecare ACOs,7 pre-hospital, emergency department, catheterization lab and intensive care unit health care systems must be addressed adequately if ACOs are to truly encompass the entire continuum of care. Overall, alternative quality measures could be constructed that more comprehensively reflect the final products of high-quality cardiovascular care (table 4). Focusing on outcomes would allow ACOs more creativity and flexibililty to develop their own evidence-based processes and process measures. Patient incentives (value-based insurance design49 and patient-level shared savings50) must also be created to increase patient participation in cardiovascular prevention efforts (for example, “Million Hearts” or “Life’s Simple 7”51, 52). Achievable quality goals with incentives of sufficient magnitude are likely to be important drivers of care for specialists within any capitated model. In fee-for-service systems, adding financial incentives may not be as important as using quality metrics to systematically drive specialist referrals.8 Emphasizing outcomes (including patient-reported outcomes) rather than process metrics could incentivize local, tailored solutions that are sufficiently flexible and innovative to achieve improvements.
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Efforts are underway to test the effectiveness of existing techniques for promoting highvalue cardiovascular care in a fee-for-service payment landscape. The ACC’s SMARTCare project was recently awarded nearly $16 million to study the cost impact of cardiologists’ use of a suite of tools to assess and improve the use of evidence-based care. Techniques to be evaluated include tracking the appropriate use of evidence-based diagnostics and therapeutics; employing point-of-care predictive modeling of the anticipated risks and benefits of procedures; and promoting patient shared decision making. Another professional organization, the Society of Thoracic Surgeons, has partnered with others (AHA, ACC, Society for Cardiovascular Angiography and Interventions) to promote an innovative “heart team” approach for patients requiring coronary revascularization or valve replacement. Heart teams garnered endorsement in the form of a CMS National Coverage Decision that required
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a multidisciplinary team based approach to the workup and treatment of aortic valve disease using transcatheter aortic valve replacement. CMS supported billing codes that allow feefor-service payments to multiple clinician team members. If it proves effective and efficient, the heart team model could be expanded over time to include alternative payment methods such as fee for service with shared savings, bundled payments and longitudinal disease management payments.
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Heart teams engaged in capitated disease management programs share conceptual similarities with specialty-based patient-centered medical homes. For these models to work well, eligible patients should have cardiovascular disorders that clearly identify them as likely to benefit from intensive management by cardiovascular specialists. Because major comorbidities and social challenges often accompany significant cardiovascular disease, carefully designed systems for care coordination will require integration of primary care providers, ancillary services and social workers. Regardless of specific format, creating a structured and mutually equitable interface between cardiologists and primary care providers will be important, given the burden of comorbidities for many patients with cardiovascular disease.
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Moving away from fee-for-service payment arrangements is a credible method of tackling overutilization.53, 54 Nonetheless, the complexity of defining relevant populations and timeframes for global payments in specialty medicine is daunting. A transition state could be envisioned in which health systems and primary care physicians engage in a qualityincentivized global payment system, while specialists continue to operate using qualitydriven fee for service. Any such arrangement would require attention to improving specialists’ attention to value considerations, population management and shared decision making.55 One major structural change that may foster more effective integration of cardiovascular specialty care into ACOs is already well underway. While there are many trade-offs involved in mergers between cardiology group practices and health systems,56 in theory this nationwide trend could allow better focus on important cardiovascular prevention and treatment across the entire continuum of care. The broader obligations and revenue sources of health systems could lead to a better balance between overutilized and underutilized cardiovascular services, toward a goal of higher value overall cardiovascular care. In practice, other factors will likely modify the effects of specialist employment models, including the level of health system exposure to capitation and bundled payments, the integration of clinicians and cardiologists into leadership positions in health systems, and methods used for tracking specialist productivity.
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How to measure success or failure It will be important to rigorously assess whether ACOs are achieving high quality cardiovascular care and outcomes while meeting their financial goals. Ultimately, health services and health policy research must define optimal combinations of payment model and organizational characteristics to maximize patient experience and outcomes while minimizing costs. A strength of the ACO construct is its promotion of flexible combinations
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of organizational structures, processes, participants and payment mechanisms. In theory this could allow for better tailoring of care within any given payment model to more effectively meet local population needs while providing payment for the important work to improve the systems of care. Detailed study is necessary to determine whether execution can match aspiration.
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While ACO’s flexibility allows incorporation of multiple stakeholders needs, this requires assessment from various vantage points with different methodologies. Parties with claims to prioritized research on ACOs include patients, clinicians, executive leaders, change agents, and policymakers. High-quality organizational research will require many health services investigators to develop expertise with new methodologies. To understand the complex interaction between payment model, organizational characteristics and patient populations, researchers must engage in much more detailed evaluations than conventional system- or payer-level economic analyses or claims-based analyses. Teaming up with organizational researchers or public health / policy researchers who already have experience with such methods could be valuable.
Conclusions
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ACOs are flexible organizations with appealing features for promoting effective and efficient health care. Cardiologists could add value for ACOs in both fee-for-service and global payment models; however systems for involving cardiovascular specialists have not yet been established. Specific modifications to ACOs could improve their focus on cardiovascular health: 1) ACO quality performance metrics should be reengineered to better represent cardiovascular outcomes and patient-reported outcomes; 2) tools proven to improve outcomes, patient experience, appropriateness of care and efficiency of care should be widely implemented; and 3) participation in learning networks using evidence-based techniques for organizational change should be promoted to accelerate improvements in care. Regardless of how the next iteration of ACOs takes shape, diligent research efforts will enable quality improvement and maximize the odds of success.
Acknowledgments Sources of Funding This work was funded by National Heart, Lung, and Blood Institute (NHLBI) grant K12 HL108974 supporting Dr Stecker.
References Author Manuscript
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43. Lewis VA, Larson BK, McClurg AB, Boswell RG, Fisher ES. The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff (Millwood). 2012; 31:1777–1785. [PubMed: 22869656] 44. [accessed July 21, 2015] http://www.oregon.gov/oha/analytics/CCOData/2015%20Measures.pdf 45. Personnel communication, Dana Safran (Blue Cross Blue Shield Massachussetts). 2015 Jul 21. 46. Berenson RA, Provonost PJ, Krumholz HM. Achieving the potential of health care performance measures. Robert Wood Johnson Foundation Timely Analysis of Health Policy Issues. 2013 [Accessed June 23, 3014] http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/ rwjf406195. 47. Porter ME. What is value in health care? The New England Journal of Medicine. 2010; 363:2477– 2481. [PubMed: 21142528] 48. Dimick JB, Staiger DO, Birkmeyer JD. Ranking hospitals on surgical mortality: the importance of reliability adjustment. Health Services Research. 2010; 45:1614–1629. [PubMed: 20722747] 49. Fendrick AM, Chernew ME, Levi GW. Value-based insurance design: embracing value over cost alone. The American Journal of Managed Care. 2009; 15:S277–S283. [PubMed: 20088631] 50. Mostashari F, Sanghavi D, McClellan M. Health reform and physician-led accountable care: the paradox of primary care physician leadership. JAMA. 2014; 311:1855–1856. [PubMed: 24723035] 51. [accessed July 1, 2014] http://mylifecheck.heart.org/Multitab.aspx?NavID=3&CultureCode=en-US 52. [accessed July 1, 2014] http://millionhearts.hhs.gov/index.html 53. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008; 299:2789–27891. [PubMed: 18560006] 54. Schroeder SA, Frist W. Phasing out fee-for-service payment. The New England Journal of Medicine. 2013; 368:2029–2032. [PubMed: 23534546] 55. Stecker EC, Schroeder SA. Adding value to relative-value units. The New England Journal of Medicine. 2013; 369:2176–2179. [PubMed: 24256346] 56. Balto, D.; Kovacs, J. [Accessed November 12, 2014] Consolidation in health care markets. 2013. http://dcantitrustlaw.com/assets/content/documents/2013/baltokovacs_healthcareconsolidation_jan13.pdf 57. Rumsfeld JS, Alexander KP, Goff DC Jr, Graham MM, Ho PM, Masoudi FA, Moser DK, Roger VL, Slaughter MS, Smolderen KG, Spertus JA, Sullivan MD, Treat-Jacobson D, Zerwic JJ. Cardiovascular health: the importance of measuring patient-reported health status: a scientific statement from the American Heart Association. Circulation. 2013; 127:2233–2249. [PubMed: 23648778]
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Figure. Accountable Care Organization Governance
Legend: Example of Blue Shield of California’s suggested governance structure for ACOs. The Sacremento CalPERS ACO16, 17 is modelled after this structure. Reproduced with permission.
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Table 1
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2015 Medicare accountable care organization quality measures most relevant to cardiovascular specialists
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CMS Quality Measure
Description
Applicable patients*
ACO #2
How well doctors communicate
Age ≥ 18 years
ACO #3
Patients rating of doctor
Age ≥ 18 years
ACO #4
Access to specialists
Age ≥ 18 years
ACO #5
Health promotion and education
Age ≥ 18 years
ACO #6
Shared decision making
Age ≥ 18 years
ACO #7
Health status / functional status
Age ≥ 18 years
ACO #8
Risk standardized all-cause readmissions
Patients ≥ 65 years old discharged from hospital†
ACO #10
ASC admission: heart failure
Patients ≥ 18 years old discharged from hospital with heart failure diagnosis
ACO #16
Adult weight screening and follow-up
Age ≥ 18 years
ACO#17
Tobacco use assessment and cessation intervention
Age ≥ 18 years
ACO # 21
Proportion of adults who had blood pressure screened in past 2 years
Age ≥ 18 years
ACO #28
Percent of beneficiaries with hypertension whose blood pressure < 140/90
Age 18 – 85 years with diagnosis of hypertension
ACO #30
Percent of beneficiaries with ischemic vascular disease who use aspirin or other antithrombotic
Age ≥ 18 years with diagnosis of ischemic vascular disease or discharged alive after acute MI, PCI or CABG
ACO #31
Beta-blocker therapy for LV systolic dysfunction
Age ≥ 18 years with a heart failure diagnosis and current or prior LV ejection fraction
Circulation. Author manuscript; available in PMC 2016 August 15. Published in final edited form as: Circulation. 2015 August 18; 132(7): 603–610. doi:10.1161/CIRCULATIONAHA.114.010269.
Accountable Care Organizations: Ensuring Focus on Cardiovascular Health Kavita K. Patel, MD, MSHS1, Joaquin E. Cigarroa, MD2, Jeffrey Nadel, BA1, Deborah J. Cohen, PhD3, and Eric C. Stecker, MD, MPH2 1Engleberg
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2Knight
Center for Health Care Reform, The Brookings Institution, Washington, D.C.
Cardiovascular Institute, Oregon Health & Science University, Portland, OR
3Department
of Family Medicine, Oregon Health & Science University, Portland, OR
Keywords Healthcare policy; Healthcare costs; health care
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While unparalleled in the provision of intensive lifesaving treatments, US health care has only begun to focus on other important aspects of population health. In order to achieve the triple aim of better health, better care and lower costs, payment and delivery systems must evolve. The accountable care movement is central to this evolution, and engagement by cardiovascular specialists can help to shape it. Sustained partnering with policymakers could improve patient care by appropriately directing cardiovascular medicine resources and avoiding unintended harm to well-functioning systems of care.
Accountable Care Organizations
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Accountable Care Organizations (ACOs) are part of a new payment and delivery model that aims to improve quality of care while controlling costs for populations of patients.1, 2 ACOs took conceptual shape nearly ten years ago as an approach to achieve these goals in a manner that fosters flexibility.3, 4 Unlike the managed care movement in the 1990s, capitated payments have not been a foundational element of the ACO movement (though components of capitation will likely prove important5). ACOs were therefore less disruptive to the status quo ante, and with inclusion in the Affordable Care Act of 2010 they gained considerable momentum. While Medicare has specific requirements for ACO structure and patient attribution, state and private insurers have engaged in a variety of alternative ACO models that could drive innovation. Within ACOs, providers can be configured in a number of ways ranging from physician-led groups and integrated delivery systems to hospital-based systems coupled with independent practice associations.2–4, 6 The adoption of electronic health
Correspondence: Eric C. Stecker, Knight Cardiovascular Institute, Oregon Health & Science University, UHN-62, 3181 SW Sam Jackson Park Road, Portland Oregon 97239; phone 503-494-7400; fax 503-494-8550; [email protected]. Disclosures Drs. Stecker and Cigarroa receive salaries with fee-for-service-based incentives and productivity tracking.
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records has been an important feature that allows ACOs to measure and integrate care for populations of patients. Regardless of structure, it is widely accepted that ACOs should: 1) be provider-led and accountable for the entire continuum of care for a population, 2) have payments structured to incentivize lower-cost, higher quality care, and 3) engage in reliable performance measurement techniques that instill confidence in the quality of care provided.2, 5 Although early forms of ACOs have focused on primary care, meaningful inclusion of specialists will be required for long-term success.7–9
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The payment model for ACOs can take several forms. Fundamentally, providers agree to be accountable for the quality of care and total cost for a population based on prior benchmark years of expenditures.6 If quality thresholds are met and the ACO saves money over the year, the savings are shared between the ACO and payer. These shared savings arrangements are the foundation of the payment model and serve as the primary incentive to practice high value health care.10 In theory, fully mature ACOs would eventually take on financial risk and achieve partial or full capitation so that payments are independent of the volume and intensity of services provided.2, 3, 11 To date, however, the majority of ACOs operate in a primarily fee-for-service environment with shared savings.
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ACOs have flourished in both the public and private sector. All major payers are engaged in accountable care contracts, including the Centers for Medicare and Medicaid Services’ (CMS) Pioneer ACO Program and Medicare Shared Savings Program. By the end of 2013, more than 600 public and private ACOs were in operation, including 366 Medicare ACOs.12 Although ACOs hold promise for curbing costs and improving quality, it is too early to tell whether they are an effective and complete solution to the systemic problems in health care.13, 14 Nonetheless early results indicate modest savings are achievable. CMS’ Pioneer ACO program showed an estimated net savings of $118 million ($29 per member per month) among 32 ACOs providing care for 566,000 Medicare beneficiaries.15 Despite these overall savings, more than half of participating organizations dropped out of the Pioneer ACO program, and continued participation was not predicted by estimated ACO savings. These results imply that greater shared savings as well as modifications to benchmarking may be required to successfully disseminate a Medicare ACO model. An example of a commercial ACO is provided by the Sacramento CalPERs ACO, established in California in 2010 by a physician group (Hill Physicians Medical Group), insurer (Blue Shield of California), purchaser (CalPERS), and hospital system (Dignity Health).16 This organization provides care for 41,000 enrollees and uses a hybrid of share savings/risk, global payments and fee for service.17, 18 The provider-payer relationship is governed in a way that allows for modular integration of additional ACOs and continuous innovation and improvement of delivery methods (Figure). The Sacramento CalPERS ACO alone has generated savings of $95 million in addition to distributing $10 million in shared savings to provider organizations while improving quality performance metrics.16 Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract program provides an example of a successful statewide program. Using modified global payment / quality contracting arrangements with ACO-like organizations, this program produced a 1.9% savings while improving quality metrics in its first year.19 Although ACO programs focused on state Medicaid populations
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have been established in Colorado, Maine, Minnesota, New Jersey, Oregon and Vermont,20 it is premature to assess their impact on quality and cost.
Cardiovascular Medicine and Accountable Care
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Cardiovascular medicine, an increasingly important focus in the accountable care movement, makes up the largest portion of health care costs.21, 22 Spending related to cardiovascular disease is projected to reach $1.5 trillion, by 203023 and it remains the leading cause of death and disability in the US.24 During the last 20 years, major improvements in the provision of evidence-based care, including both preventive and catastrophic care, have led to significant reductions in morbidity and mortality.25–27 However, there has been little attention to societal cost efficiencies when designing new systems of care. A change in payment structure, better care coordination, augmented data, and improved care management—hallmarks of accountable care—could enable improvements in health and more efficient use of cardiology expenditures.
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Despite the high burden and cost of disease, defining where cardiology fits into accountable care models has been difficult. To date, ACO models have primarily engaged primary care providers and are just now starting to incorporate specialists and specialty care.8 One example, Oregon’s Coordinated Care Organization (CCO) model, has yielded encouraging preliminary results. CCOs were established in 2012 and are collaborative networks of health care providers—both in primary and specialty care—caring for patients covered under the Oregon Medicaid plan. The combination of a CCO focus on decreasing all-cause hospitalizations and an independent focus by hospitals and cardiology service lines on decreasing heart failure readmissions (due to Medicare payment reforms) has led to a 27% reduction in overall hospitalizations for congestive heart failure.28 Further, Florida Blue Cross Blue Shield has launched a number of commercial ACO contracts with the goal of controlling high-cost areas such as cardiovascular medicine by focusing on heart failure and including cardiologist in shared savings arrangements.29
Supporting Cardiology Quality Improvement within ACOs
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Professional organizations can assist in the successful implementation of ACOs by providing access to registries, supporting organizational learning communities, incorporating accountable care into graduate medical education and continuing medical education, and creating tools for clinical practice that maximize appropriate care. Such support and resources can simplify the challenge of adopting effective systems of care and improving outcomes. For example, the ACC’s National Cardiovascular Data Registry (NCDR) and the American Heart Association’s (AHA) Get With the Guidelines (GWTG) registries constitute a collection of nine hospital-based registries and two outpatient registries. NCDR alone includes over 2,400 hospitals and approximately 1,000 outpatient providers.30 These registries provide benchmarked process and outcome data with greater detail and timeliness (and therefore actionability) than the claims-based information provided by payers. Employing appropriate use criteria to evaluate practice- and hospital-level patterns of cardiovascular care also has the potential to improve quality and control costs. Appropriate
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use criteria define evidence-based, professional-consensus-driven standards for using tests and therapies. These criteria serve as adjuncts to practice guidelines by highlighting common or controversial clinical scenarios that may require nuance beyond that readily available from the primary analysis of randomized clinical trials. Although there is a focus on overuse, these tools can also allow assessment for underuse of high-value clinical services. The methodology, developed in a collaboration between RAND and UCLA, has several important features: a standardized development approach; an unbiased literature review as the basis for evaluation; clinician input regarding the most important clinical scenarios to be evaluated; and at least two rounds of review by a panel of content experts (first round alone, second round as a group to work toward consensus).31
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Participating in national collaborative programs with peer organizations could also accelerate the quality improvement measures that are critical to the accountable care movement. The ACC and AHA have undertaken major national initiatives to create learning communities for health systems and providers to facilitate organization-level improvement in cardiology. For example, a program focusing on strategies to improve door-to-balloon time for ST-elevation myocardial infarctions (originally named D2B Alliance, now D2B:Sustain the Gain32) has led to marked organizational changes in participating health systems.25 Expanded use of such programs could help ACOs improve the overall effectiveness and efficiency of cardiovascular care.
Potential Challenges
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Despite the promise of ACOs, effective integration of specialists is unproven and faces challenges. For example, a study evaluating patterns of use of discretionary cardiovascular imaging and procedures in a Medicare pilot ACO program (the Physician Group Practice Demonstration program; PGDP) showed no impact on utilization.33 While there are inherent methodological limitations (difference-in-difference rather than randomized analysis, claims-based rather than registry-based variables), this study indicates that policies meant to alter specialty care patterns can be contravened by a variety of potential factors including fee-for-service payments, magnitude / alignment of financial incentives, degree of focus on specialty care, and overall heterogeneity in accountable care systems.
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A fundamental challenge is that specialists engage in the care of patients in a different manner than generalists. Unlike primary care providers, most surgical specialists and many cardiologists (e.g., electrophysiologists, interventionalists) engage in patients’ care for a limited time with a narrow scope. Some cardiologists may practice in a hybrid model in which they assume long-term responsibility for some disorders (e.g., severe heart failure) and episodic responsibility for others (e.g., ischemic heart disease, arrhythmias). Cardiologists, emergency medicine physicians, and others also routinely engage in complex systems of care that are time dependent such as ST-elevation myocardial infarction (MI) and cardiac arrest treatment. Conventional ACO designs may not adequately address quality considerations in this hyperacute phase of the continuum of care.7 Together these challenges add considerable complexity to the task of appropriately attributing quality, outcomes, costs and incentives for ACO specialty care.
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Measuring the health benefits attributable to specialty care is also complex. For example, while few medical procedures have more direct impact on morbidity and mortality than prompt reperfusion for ST-elevation MI, its benefits can be challenging to describe at the population level. One large study analyzing mortality after ST-elevation MI showed no improvement, despite dramatic improvements in door-to-balloon times.34 Inferences that this reflects a lack of primary percutaneous coronary intervention efficacy are tempting but may be inaccurate (potentially an ecological fallacy due to increasing risk among procedural patients over time). Overall, comparisons of outcomes must carefully control for different levels of clinical risk at both patient and population levels. The debate over using socioeconomics in risk adjustment for hospital readmissions35–37 illustrates the complexities entailed when comparing and incentivizing population-based quality measures in heterogeneous contexts. Given the many factors that influence health, it can be difficult to define the scope of health care providers’ responsibility for health outcomes.
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There are inherent statistical limitations to measuring quality outcomes at the level of small health systems and most physician groups. In the past there has been focus on risk adjustment, but statistical noise often overwhelms signal even for risk-adjusted measures if denominators are small. In fact, an analysis commissioned by CMS showed that fewer than half of US hospitals had sufficient patient volume to achieve moderate statistical reliability over 24 months of data accrual for 30-day risk-adjusted mortality and readmission rates.38 Similarly, few hospitals have sufficient volume to use surgical mortality as a statistically reliable indicator of quality for most types of operations.39
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Even if measurement methods are accurate, aligning quality with profits is challenging and can introduce ethical concerns. As alluring as it has been for health systems to build highcost cardiology infrastructures to maximize market share and revenue under fee-for-service payment systems, it may be equally alluring to aggressively scale back cardiology costs if capitation arrangements become the dominant payment method. Creating robust quality measurement systems that are overseen by the critical stakeholders (including patients, primary care providers, cardiovascular specialists, and administrators) will minimize the risk of inappropriate use or withholding of cardiovascular care in ACOs. Current quality measurement and governance structures are not yet mature. For example, cardiologyrelevant performance metrics for Medicare ACOs40 (table 1) do not evaluate outcomes for patients with cardiovascular disease; and many ACOs governance structures appear to have limited representation by patients and specialists.
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The coexistence of fee-for-service and global payments during transition periods may limit the ability of cardiologists and ACOs to adopt efficient and effective systems of care. In a predominantly capitated system, the primary trade-off to consider when improving the efficiency of medical care is whether quality will be adversely impacted. In a mixed payment environment, the tradeoffs become more complex. Improvements in efficiency could decrease revenue under fee for service such that they undermine reform efforts.13 Constructing effective payment and delivery models for rural and socially disadvantaged populations is also challenging. Medicare ACOs operate in 43% of metropolitan counties and only 17% of non-metropolitan counties.41 Anticipating the lower capital reserves of
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rural organizations, CMS has created an “advanced payment option.” Qualifying ACOs receive upfront payments to help fund start-up infrastructure and personnel that will lead to later savings.42 Disadvantaged populations have similar challenges in attracting wellcapitalized health care organizations and could also benefit from advanced payments.43 Despite such challenges, both rural and disadvantaged populations could greatly benefit from a shift to ACOs if funding and organizational obstacles can be overcome.
Potential Solutions
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Regardless of payment model (fee-for-service, capitated or mixed), maximizing the cardiovascular health of ACO populations will aided by more sophisticated quality measures. Existing performance metrics40, 44, 45 (tables 1, 2 and 3) are dominated by process measures and admission/readmission measures. However, these metrics encompass only a small portion of well-functioning systems of care and are unproven surrogates for mortality, important patient-reported outcomes and patient experience.46, 47 In addition, the value of well-functioning systems for hyperacute conditions such as ST-elevation MI, out-of-hospital cardiac arrest and stroke must be measured and appropriately incentivized. While the requirement for addressing the entire spectrum of care precludes suggestions to create acutecare ACOs,7 pre-hospital, emergency department, catheterization lab and intensive care unit health care systems must be addressed adequately if ACOs are to truly encompass the entire continuum of care. Overall, alternative quality measures could be constructed that more comprehensively reflect the final products of high-quality cardiovascular care (table 4). Focusing on outcomes would allow ACOs more creativity and flexibililty to develop their own evidence-based processes and process measures. Patient incentives (value-based insurance design49 and patient-level shared savings50) must also be created to increase patient participation in cardiovascular prevention efforts (for example, “Million Hearts” or “Life’s Simple 7”51, 52). Achievable quality goals with incentives of sufficient magnitude are likely to be important drivers of care for specialists within any capitated model. In fee-for-service systems, adding financial incentives may not be as important as using quality metrics to systematically drive specialist referrals.8 Emphasizing outcomes (including patient-reported outcomes) rather than process metrics could incentivize local, tailored solutions that are sufficiently flexible and innovative to achieve improvements.
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Efforts are underway to test the effectiveness of existing techniques for promoting highvalue cardiovascular care in a fee-for-service payment landscape. The ACC’s SMARTCare project was recently awarded nearly $16 million to study the cost impact of cardiologists’ use of a suite of tools to assess and improve the use of evidence-based care. Techniques to be evaluated include tracking the appropriate use of evidence-based diagnostics and therapeutics; employing point-of-care predictive modeling of the anticipated risks and benefits of procedures; and promoting patient shared decision making. Another professional organization, the Society of Thoracic Surgeons, has partnered with others (AHA, ACC, Society for Cardiovascular Angiography and Interventions) to promote an innovative “heart team” approach for patients requiring coronary revascularization or valve replacement. Heart teams garnered endorsement in the form of a CMS National Coverage Decision that required
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a multidisciplinary team based approach to the workup and treatment of aortic valve disease using transcatheter aortic valve replacement. CMS supported billing codes that allow feefor-service payments to multiple clinician team members. If it proves effective and efficient, the heart team model could be expanded over time to include alternative payment methods such as fee for service with shared savings, bundled payments and longitudinal disease management payments.
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Heart teams engaged in capitated disease management programs share conceptual similarities with specialty-based patient-centered medical homes. For these models to work well, eligible patients should have cardiovascular disorders that clearly identify them as likely to benefit from intensive management by cardiovascular specialists. Because major comorbidities and social challenges often accompany significant cardiovascular disease, carefully designed systems for care coordination will require integration of primary care providers, ancillary services and social workers. Regardless of specific format, creating a structured and mutually equitable interface between cardiologists and primary care providers will be important, given the burden of comorbidities for many patients with cardiovascular disease.
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Moving away from fee-for-service payment arrangements is a credible method of tackling overutilization.53, 54 Nonetheless, the complexity of defining relevant populations and timeframes for global payments in specialty medicine is daunting. A transition state could be envisioned in which health systems and primary care physicians engage in a qualityincentivized global payment system, while specialists continue to operate using qualitydriven fee for service. Any such arrangement would require attention to improving specialists’ attention to value considerations, population management and shared decision making.55 One major structural change that may foster more effective integration of cardiovascular specialty care into ACOs is already well underway. While there are many trade-offs involved in mergers between cardiology group practices and health systems,56 in theory this nationwide trend could allow better focus on important cardiovascular prevention and treatment across the entire continuum of care. The broader obligations and revenue sources of health systems could lead to a better balance between overutilized and underutilized cardiovascular services, toward a goal of higher value overall cardiovascular care. In practice, other factors will likely modify the effects of specialist employment models, including the level of health system exposure to capitation and bundled payments, the integration of clinicians and cardiologists into leadership positions in health systems, and methods used for tracking specialist productivity.
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How to measure success or failure It will be important to rigorously assess whether ACOs are achieving high quality cardiovascular care and outcomes while meeting their financial goals. Ultimately, health services and health policy research must define optimal combinations of payment model and organizational characteristics to maximize patient experience and outcomes while minimizing costs. A strength of the ACO construct is its promotion of flexible combinations
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of organizational structures, processes, participants and payment mechanisms. In theory this could allow for better tailoring of care within any given payment model to more effectively meet local population needs while providing payment for the important work to improve the systems of care. Detailed study is necessary to determine whether execution can match aspiration.
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While ACO’s flexibility allows incorporation of multiple stakeholders needs, this requires assessment from various vantage points with different methodologies. Parties with claims to prioritized research on ACOs include patients, clinicians, executive leaders, change agents, and policymakers. High-quality organizational research will require many health services investigators to develop expertise with new methodologies. To understand the complex interaction between payment model, organizational characteristics and patient populations, researchers must engage in much more detailed evaluations than conventional system- or payer-level economic analyses or claims-based analyses. Teaming up with organizational researchers or public health / policy researchers who already have experience with such methods could be valuable.
Conclusions
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ACOs are flexible organizations with appealing features for promoting effective and efficient health care. Cardiologists could add value for ACOs in both fee-for-service and global payment models; however systems for involving cardiovascular specialists have not yet been established. Specific modifications to ACOs could improve their focus on cardiovascular health: 1) ACO quality performance metrics should be reengineered to better represent cardiovascular outcomes and patient-reported outcomes; 2) tools proven to improve outcomes, patient experience, appropriateness of care and efficiency of care should be widely implemented; and 3) participation in learning networks using evidence-based techniques for organizational change should be promoted to accelerate improvements in care. Regardless of how the next iteration of ACOs takes shape, diligent research efforts will enable quality improvement and maximize the odds of success.
Acknowledgments Sources of Funding This work was funded by National Heart, Lung, and Blood Institute (NHLBI) grant K12 HL108974 supporting Dr Stecker.
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Figure. Accountable Care Organization Governance
Legend: Example of Blue Shield of California’s suggested governance structure for ACOs. The Sacremento CalPERS ACO16, 17 is modelled after this structure. Reproduced with permission.
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Table 1
Author Manuscript
2015 Medicare accountable care organization quality measures most relevant to cardiovascular specialists
Author Manuscript Author Manuscript
CMS Quality Measure
Description
Applicable patients*
ACO #2
How well doctors communicate
Age ≥ 18 years
ACO #3
Patients rating of doctor
Age ≥ 18 years
ACO #4
Access to specialists
Age ≥ 18 years
ACO #5
Health promotion and education
Age ≥ 18 years
ACO #6
Shared decision making
Age ≥ 18 years
ACO #7
Health status / functional status
Age ≥ 18 years
ACO #8
Risk standardized all-cause readmissions
Patients ≥ 65 years old discharged from hospital†
ACO #10
ASC admission: heart failure
Patients ≥ 18 years old discharged from hospital with heart failure diagnosis
ACO #16
Adult weight screening and follow-up
Age ≥ 18 years
ACO#17
Tobacco use assessment and cessation intervention
Age ≥ 18 years
ACO # 21
Proportion of adults who had blood pressure screened in past 2 years
Age ≥ 18 years
ACO #28
Percent of beneficiaries with hypertension whose blood pressure < 140/90
Age 18 – 85 years with diagnosis of hypertension
ACO #30
Percent of beneficiaries with ischemic vascular disease who use aspirin or other antithrombotic
Age ≥ 18 years with diagnosis of ischemic vascular disease or discharged alive after acute MI, PCI or CABG
ACO #31
Beta-blocker therapy for LV systolic dysfunction
Age ≥ 18 years with a heart failure diagnosis and current or prior LV ejection fraction
