1. Patient policies are a weak part of ACOs. “There has been little discussion on how patients would fit into ACOs,” Dr. Rosenthal says. “I’m not sure the model that has been talked about is going to work.” Under that model, CMS will assign beneficiaries to an ACO, based on each beneficiary’s historic pattern of care, but patients would be allowed to use providers outside the ACO. It is up to the ACO to persuade them to stay in its network for providers.
2. Why ACOs were left wide open. The planners of ACOs chose not to stop beneficiaries from seeking care outside the ACO because they were wary of setting off another backlash as happened with HMOs in the 1990s. Moreover, “Medicare is always reluctant to do anything that is perceived by beneficiaries as restricting their access,” Dr. Rosenthal says. “It’s a hot-button issue.”
3. Most patients would stay within the ACO. Planners were heartened that an open-ended ACO would work because almost three-quarters of Medicare beneficiaries limit basic healthcare services to a particular hospital and the physicians on its staff, a network that is basically what an ACO would be. However, this statistic also suggests that more than one-quarter of beneficiaries would not stay within the ACO network and would need incentives to do so.
4. Tie patients to ACOs by lowering copayments. Dr. Rosenthal suggests CMS could incentivize beneficiaries to use their assigned ACO by reducing their out-of-pocket charges when they use providers in the ACO network. They could still go to a non-ACO provider but they would pay a higher copayment. This is currently not part of ACO planning but it could be inserted in proposed ACO regulations that CMS is drafting.
5. Lock in patients with a lower premium. She also suggests a more aggressive model, in which patients pay a lower premium if they will commit to a particular ACO. “This would be a lock-in,” Dr. Rosenthal points out. But beneficiaries could exit the arrangement in the next enrollment period. This is also not part of current ACO planning.
Would there be enough funds for this? To finance the lower copayments and premiums, ACOs might have to share any savings they realize. However, it is not certain whether that many ACOs would generate any savings at all, at least at first. In the Medicare Physician Practice Demonstration, the model for the ACO program, only a few participants generated savings, even as all of them were rewarded for improving quality metrics. “People talk about ACOs improving quality but we all know the main aim is to produce savings,” Dr. Rosenthal says.
Read the New England Journal of Medicine article on ACOs.
