Physicians Key Leaders In ACOs, But Surgeons Are Overlooked
By Christine Kern, contributing writer
A recent survey finds surgeons are largely overlooked for leadership roles in ACOs.
A new study finds that, while doctors have a sizable role in the governance of ACOs, surgeons have been largely overlooked for executive committee memberships and in quality measures. Two newly published surveys take a closer look at who is at the helms of the first ACOs and what their early priorities have been.
The research, published in the latest issue of the policy journal Health Affairs, provide insights into ACOs in operation in 2012, the first year that Medicare joined a trickle of public sector accountable-care efforts.
According to the study, doctors who use their influence to promote quality and efficiency efforts are important, and one way to build trust to win over physicians is by adding physicians to governing. The research demonstrates that early ACOs have done precisely that. Doctors accounted for more than half the governing board among three quarters of the 173 public and private ACOs surveyed by Carrie Cola, Valeria Lewis and Elliott Fisher of Dartmouth University and Stephen Shortell of the University of California at Berkeley. Doctors owned 40 percent of the ACOs in operation as of August 2012.
ACOs described as “physician-led” composed 51 percent of survey respondents and another 33 percent were led by doctors and hospitals.
In a separate survey, physician-led Medicare ACOs dominated the four case studies (three out of four) profiled in a second Health Affairs analysis. The ACOs prioritized fewer readmissions and emergency room visits, more coordination for the chronically ill and did not include surgical care. Further, surgeons were not represented on the executive committee of two of the four ACOs. Additionally, 14 of 28 early Medicare ACOs surveyed said no surgeons sat on their executive committee.
The absence of surgeons was explained by the researchers in this way: “Notably, none of CMS' 33 ACO quality measures directly addresses surgery or surgical care,” wrote authors James Dupree, formerly of the American College of Surgeons; Kavita Patel of the Brookings Institution; Mallory West, formerly of Brookings; and Sara Singer, Rui Wang, Michael Zinner and Joel Weissman of Harvard University. Therefore, surgeons were not considered part of the quality measurement equation. Quality measures must be met under Medicare's accountable care program before ACOs can earn financial bonuses.
The researchers also wrote that surgeons also lack a strong incentive to join ACOs. The relatively minor ACO incentives are believed to be too inconsequential to change surgeons' behavior on quality or cost targets, case study ACO officials said.
Surgery failed to rank among the high-priority targets for ACOs, the paper said, and 88 percent of surveyed ACOs did not know what role surgery played in total spending.
However, that may prove to be a costly oversight. “Nationally, surgery represents approximately 50 percent of hospital expenditures and accounts for an estimated 30 percent of total healthcare costs,” the authors wrote. “Thus, even if ACOs are able to achieve their goals in chronic disease management, overlooking the role and cost of surgical care may negate those savings.” ACOs might need to rethink their governance structure to capitalize on the role of surgery for the bottom line of their healthcare organizations.
Under the ACA, Medicare was called upon to launch ACOs, and the program had established 370 organizations as of January 2014, with more on the horizon. Some state Medicaid plans also have entered accountable care contracts with doctors and hospitals. New incentives under accountable care could erode the inducement for providers to do multiple tests and procedures when insurance companies pay by the exam, clinic visits or laboratory test.
However, the incentives for the earliest ACOs are considered too small and weak, and it is really physicians who will use their clout to sway others to change practice patterns who are the key to ACOs' success, researchers wrote in Health Affairs.