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UTHSCSA

Following a Different Model of

CARE

Accountable Care Organizations focus on

improving patient health, experience while reducing costs

By Ramon Cancino, MD, MSc, Director of Primary Care, UT Health Physicians

virgen Rodriguez-Perez, M.d., a UT Health Physicians family must be different as well. Traditional fee-for-service care practices
medicine physician, remembers a different time. are designed to see a high volume of patients, while high-perform-
“In my other practice, we were seeing as many patients as possible ing ACOs often collaborate with hospitals, have physician leaders
because that was the way we made money,” she said. focused on improving performance, utilize sophisticated informa-
Primary care physicians across Texas are used to practicing under tion systems, provide effective feedback to physicians, and have em-
this model. Traditional fee-for-service care incentivizes high patient bedded care coordinators.
visit volumes rather than high quality care. This type of medical The U.S. health care market was not always focused on value, but
practice is often not patient-centered and can lead to unnecessary the U.S. has a history of attempting to restructure U.S. health care
and often redundant utilization of health care resources, disjointed to decrease costs. Previous attempts to restructure care delivery have
care and poor patient outcomes. included the Health Maintenance Organizations of the 1980s and
dr. Rodriguez-Perez now follows a different model, and her pa- 1990s and the Medicare Physician Group Practice demonstration
tients are benefiting, she said. pilot program in the mid-2000s. Costs continued to rise. In 2011,
“Now, before many of my patients arrive, my medical assistant the U.S. department of Health and Human Services, via Medicare
and I know what cancer screenings are due, whether or not they program section 3022 of the Patient Protection and Affordable
have recently been to an emergency room or hospital, and when Care Act of 2010, created ACOs in an effort to contain rising U.S.
their last diabetic foot exam was,” dr. Rodriguez-Perez said. “I can health care costs by helping physicians, hospitals and other health
focus on prevention and, if my patient gets sick, our team can get care providers better coordinate care for patients.
that patient into the office the same day to avoid having to send The term ACO has had many definitions. The term “accountable
that patient to the emergency room.” care organization” was originally used by dr. Elliott Fisher in 2006
The model she describes, value-based care, is one that focuses on during a public meeting with the Medicare Payment Advisory Com-
achieving what is known as the Triple Aim, improving a population’s mittee. The Centers for Medicare and Medicaid Services define an
health and patient experience while controlling avoidable costs. ACO as “groups of doctors, hospitals and other health care
Quality is often measured using Healthcare Effectiveness and In- providers who come together voluntarily to give coordinated high-
formation Set metrics and the patient experience. Costs are meas- quality care to their Medicare patients.” In general, the ACO frame-
ured by factors such as avoidance of emergency room visits for work focuses on ensuring that all patients, especially the chronically
ambulatory care, sensitive conditions and hospital readmissions. In- ill, receive the right care at the right time.
centives are based on their performance on these measures for spe- Since 2011, value-based purchasing contracts and ACOs have
cific patient populations. In the U.S., many more practices are now multiplied. As of 2015, there are about 744 ACOs in the public and
practicing both fee-for-service care and value-based care models. commercial sectors. In the public sector, the Medicare Shared Sav-
The latter is the cornerstone principle around which Accountable ings Plan has nearly 480 participating organizations as of January
Care Organizations are structured. 2017. This program rewards providers who deliver high-quality and
low-cost care to Medicare patients. Similar contracts are being done
The value of ACOs in the commercial sector, such as blue Cross blue Shield’s Alterna-
because the goals of value-based care are different from those tive Quality Contract in Massachusetts. In both examples, providers
of fee-for-service care, the structure through which care is delivered enter into an agreement with an insurer to take on financial risk as-
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