Specialty ACOs: A promising option

When accountable care organizations (ACOs) originated in 2011, their founders sought to reduce costs and improve outcomes in primary care. Recently, these aims have broadened to include overseeing patients with cancer, end-stage renal disease and certain other diseases and chronic conditions. Contracting with specialty physician groups has become the hallmark of care management for these patients.

As with traditional ACOs operating in the realm of primary care, specialty ACOs reward providers for meeting key quality measures - for example, by reducing hospital readmissions and lowering overall drug costs. But specialty ACOs must be able to stratify their patient pool based on a chronic condition or contributing risk factors, and they need to collaborate with primary care ACOs in providing care for chronically ill patients.  

The Affordable Care Act (ACA) has been the impetus for revamping traditional healthcare payment models, shifting from a volume-based to a value-based framework. And while it’s early to say definitively whether forming or joining a specialty ACO would be a better option than establishing or participating in a traditional ACO, there are some factors managed healthcare executives should consider in their decision-making.

“When we first started moving to this concept of accountable care organizations, one of the thoughts was that care should be delivered differently,” says Raena C. Akin-Deko, MHSA, assistant vice president of product development at the National Committee for Quality Assurance (NCQA) in Washington D.C.,  which accredits ACOs.

“Most of the care that we have right now is organized around the site of care,” she adds, with patients typically seeing a primary care physician for preventive health needs and specialists for complex conditions. Over time, with the growth and fine-tuning of ACOs, “the care should transcend the boundaries of a particular site of care and really focus on how to care for a population over time and across different settings.”

NEXT: Value versus volume

Value versus volume

Emphasizing value over volume in service delivery, specialty ACOs can be structured to operate in partnership, rather than conflict, with primary care ACOs, says Shelley Price, M.S., FHIMSS, director of payer and life sciences at the Healthcare Information and Management Systems Society (HIMSS) in Arlington, Virginia.

“There’s tremendous opportunity across the healthcare system to take advantage of new accountable care approaches,” she says, citing as an example the high costs and quality of life challenges associated with an aging population in need of medical care.

In the vast field of oncology, new therapeutics have transformed some forms of cancer care into chronic, treatable conditions. This allows healthcare to “attack the treatment of cancer and specialty care in a more valued-based perspective,” Price adds. “We will see that there are some commonalities between specialty ACOs and traditional primary care ACOs in that they both have opportunities to standardize care, care pathways, and coordinate care.”

Specialty ACOs can accomplish these goals by “wrapping in care coordination” and transitions of care for patients from one type of facility to another--such as from the hospital to home care or to skilled nursing facilities--which isn’t a common occurrence for traditional ACOs. Coordinating with specialty pharmacies and leveraging the knowledge of patient navigators also could have a positive influence on outcomes and costs, Price says.

Proponents of specialty ACOs view targeted care as more effective in managing specific disease states, not only cancer and end-stage renal disease, but also chronic kidney disease and some pediatric illnesses--mainly cystic fibrosis, muscular dystrophy and juvenile diabetes. Consistency of care, which relies heavily on evidence-based protocols and utilizes specialists, also provides a more natural “medical home” that lends to better patient experience and support, says Scott Kolesar, principal and national leader of the value-based care practice at Deloitte Consulting LLP.

In order to succeed, a disease-specific ACO must have a large established patient base as well as access to an extensive managed care population, usually within a major metropolitan area. If not, it must create a significant base through aggregation or collaboration. Otherwise, it won’t be an attractive proposition to payers in setting up group purchasing arrangements, Kolesar says.

A challenge many specialty ACOs face, Kolesar adds, is that, “many chronic diseases typically have low patient volume and the population may not have enough members to assume a risk-based contract.”

The path to developing a high-functioning ACO begins with an analysis of a particular patient pool’s health status. Then it’s a matter of figuring out which services and providers can help improve the health of that population while also eradicating waste in the fragmented healthcare system, says Julian D. (Bo) Bobbitt Jr., J.D., a partner and head of the health law group at Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan LLP, in Raleigh, North Carolina.

This methodology contrasts the current health status with the ideal health status for that population. “Primary care providers have been the darlings of early ACOs,” adds Bobbitt, author of guides for the Toward Accountable Care Consortium and Initiative, spearheaded by the North Carolina Medical Society to help specialists successfully integrate into ACOs. “Even so, virtually every specialty can contribute significantly to accountable care’s population health management.”

As structured under the Medicare Sharing Savings Program, ACOs focus on primary care rather than specialties. The role of oncology in ACOs has yet to be fully defined, says Matthew Farber, director of provider economics and public policy at the Association of Community Cancer Centers in Rockville, Maryland. “For example, with variables like the high cost of cancer care, oncologists being able to join multiple ACOs, and the annual setting of benchmarks, it is not clear how cancer providers have taken to the Medicare ACO model,” he says.

NEXT: The oncology ACO

The oncology ACO

However, the rise of oncology ACOs shows promise as an alternative payment model. Much like the oncology medical home model, this type of ACO tries to streamline care for patients by reducing duplication of services, keeping them out of the emergency department or the hospital entirely, and reducing care at the end of life by increasing advanced planning and education at the front end.  

“As private payers are looking for innovative models, specialty-specific ACOs are a viable option, as long as the payer is willing to work with providers on the development of benchmarks, quality reporting and risk sharing,” Farber says.

Nephrology is also making inroads in  ACO formation. Specialty ACOs called End-Stage Renal Disease Seamless Care Organizations (ESCOs) would facilitate better care management for patients by “fixing the gap between hospital and dialysis provider,” says Thomas H. Hostetter, M.D., a professor of medicine and vice chair for research at Case Western Reserve University School of Medicine in Cleveland, Ohio.

In the past, many hospitals operated their own dialysis units for inpatient as well as outpatient needs. “That’s rapidly going away, so it’s like one hospital system talking to another. That is not a seamless operation,” says Hostetter, chair of the American Society of Nephrology’s public policy board.

“Without some more organized way of getting the discharge summary and some direct communication with the hospital, the hospital admission can be a mystery to the outpatient dialysis unit,” he adds. “Almost always, there are things that happened in the hospital that have a bearing on how their dialysis is being conducted as an outpatient.”

In pediatrics, the adult model for ACOs does not easily apply, making it difficult to include both children and adults in the same ACO. Many pediatric healthcare organizations and state Medicaid programs are experimenting with different scenarios to design ACO structures that would provide similar benefits to children, says Deborah Wells, M.S., CPHIMS, senior strategy consultant in information systems at the Children’s Hospital of Philadelphia.

Effective management of adults with chronic conditions can reduce hospital stays, emergency department visits, and other complications that may lead to big healthcare spending. For the small number of children with severe congenital disorders, additional proactive intervention may not avoid catastrophic expenditures resulting from their complex disease states.

Meanwhile, Wells says, “improved preventive care for well children--vaccines and checkups, for example--will not provide high enough near-term cost savings to help an ACO meet its shared savings goals.”

Managing large numbers of patients with the same underlying illness and comorbidities makes it easier for an ACO to perform care coordination and use common approaches to resolve similar problems, says David B. Muhlestein, Ph.D., J.D., director of research at Leavitt Partners LLC, a healthcare intelligence business located in Salt Lake City, Utah.

“With volume comes experience. That’s the theory behind it,” he says. “In practice, it’s really too early to say if the specialty ACOs are going to do better than the basic ACOs.”

Even with traditional ACOs, however, the results have been mixed. Some providers and disease states have demonstrated better results than others. Muhlestein, who oversees a database of mainly non-specialty ACOs, is looking into possible explanations for the variability.

As of October, when Leavitt Partners released its most recent tracking numbers, there were a total of 646 ACOs--a surge from 82 ACOs in the second quarter of 2011. “We’re spending a lot of time studying that right now and trying to figure out what is correlated with results. It’s a challenge,” he says.

“A lot of times the ACOs themselves don’t necessarily know what they did that made a difference. It’s not like a randomized trial where they try one thing at a time and see what the effect was. They’re trying 50 different things at once--changing their practice patterns and changing their technology platforms and hiring additional workforce people to manage populations. It’s a little bit tricky to figure out what’s making a difference.”  

Susan Kreimer is a New York-based freelance medical writer.