The New ACOs

A new day is rising in the world of healthcare. As the days pass, more and more of the provisions of the ACA are being tested, and implemented. And, the new kid on the block is the ACO — the Accountable Care Organization.

ACOs have been discussed for the past year. Lots of discussion and opinions have been whirling about, but, no one actually knew (or still knows) what an ACO is. The term certainly provokes the memories of HMOs and capitation — a dance the medical community went through two decades ago. Others argue it’s not capitation at all; it’s much different. What exactly an ACO “is” appears to be the subject of a 429 page document released from CMS (the Center of Medicare and Medicaid Services) on March 31, 2011. 

The idea of the ACO is to defragment medical care. As it currently stands, many patients see many different practitioners. They have a doctor who manages their diabetes, one who manages blood pressure, and yet another who manages their anemia. With many specialists, there are patients who frequently do not bother to see their primary care physician who is left to manage nothing. And, when these complex patients present to the emergency department for an exacerbation of their chronic diseases, yet another specialist — a hospitalist, will assume their care because none of their physicians wants or can be their primary. This is fragmentation, and we see it all the time.

The ACO steps in here. An ACO is an organization created to coordinate care exactly in this situation. The ACO is made up of physicians and hospitals, and together, their objective is to provide more coordinated, higher quality, cost effective care. It is to defragment the complex. Ideally, the ACO would take ownership of these patients and see them through their chronic AND acute problems. In doing so, the thinking is that the care would be streamlined. There would be less repetition and more concise care. Ultimately, the patient would receive higher quality care and the costs of care would decrease.

We are at the beginnings of a 60 day comment period on these guidelines. By late 2011, the ACOs will be up and running, with their rules laid out. So many questions lurk. Will the large ACOs (by statute, must be at least 5,000 patients) own so much market as to suppress competition and command higher prices? Is there a sufficient army of primary care physicians willing and able to fill the role of an ACO? How will the ED get entwined in the ACO? Surely there will be incentive and pressure upon us to find options to admission which are lower in cost. But will the cost of healthcare really go down when there are 65 new standards by which quality will be judged?

There are so many unknowns in the future of health care delivery in the United States. We, as emergency physicians, are seated in a very interesting place. We are at the epicenter of a patient’s catastrophic illness. We are the cog that may never break. We, as a community, need to be aware and present during these changing times, and make sure that the emergency department is still able to serve as the safety net of the community.