CMS's Pioneer ACO May Lose Nearly Half Of Its Participants

By Lisa Kerner, contributing writer

While Pioneer may be losing participants, other ACOs are thriving

The slow-turning wheels of government could mean a fast exit for 9 of 32 hospitals and health systems participating in the Pioneer ACO Model. In addition, another four may be leaving Pioneer to join accountable care organizations (ACOs) with less financial risk, according to a Bloomberg report.

Pioneer ACO, launched by the CMS Innovation Center, was designed to show how particular ACO payment arrangements can best improve care and generate savings for Medicare, and to test alternative program designs to inform future rulemaking for the Medicare Shared Savings Program.

One possible reason participants are leaving of Pioneer, according to Presbyterian Healthcare Services Jim Hinton – who is also the chairman-elect of the American Hospital Association – is, “Participating hospitals are responsible for controlling costs for a population of Medicare patients assigned to them, but their ability to manage the patients’ care is limited. For example, they can’t forbid the patients from seeing doctors or other health providers who aren’t part of the Pioneer system.” Bloomberg notes a second reason being, “Medicare has lagged, by about six months, in providing the Pioneer systems medical claims data they need to track spending on their assigned patients.”

While Pioneer is facing the reality of seeing its membership cut by more than a third, other regional health systems are reaping the benefits of banding together. “We’re moving away from fee-for-service payments into a world where providers are recognized for taking better care of their patients and keeping them healthy,” said Craig Brammer, VP of the Greater Cincinnati Health Council, the Health Collaborative and HealthBridge, in a Cincinnati.com article.

The article highlights two ACOs that are working to manage patients’ health and prescriptions after hospital discharge - one group of 19 physician practices and another group of 14. Both groups receive monthly payments from large employers, health insurers, and Medicare for each patient that receives enhanced coordinated care at new patient-centered medical homes.

A second burgeoning ACO success story is told by Gary Katz, president and CEO of Rockford, IL Health System, on JournalStandard.com. “We’re at the point now that healthcare has become unaffordable to businesses and companies, government, wealthy people, the middle class, and the working poor. It’s unaffordable to everybody, so now we get permission to really knock the doors down and develop stuff that hasn’t happened in decades.”

Rockford is considering an ACO – its parent company OSF HealthCare is a Pioneer ACO member – and its OSF Saint Anthony Medical Center is furthest along in the process. “The concept of population health management, shared savings arrangements, and the concept of compensation based on clinical outcomes are all phenomenal and long overdue,” Katz said.

Despite Katz’ enthusiasm of ACOs and the number currently operating – according to The Economist more than 250 have been formed – they are still no sure thing as Pioneer is finding out. “ACOs are responsible for the costs of a given set of patients, but those patients can seek treatments outside the group of providers that form the ACO. This may make it hard to contain their costs,” writes The Economist.

It concludes by quoting George Clairmont, who leads a doctors’ group that partners with Steward Health Care Systems of Massachusetts, as saying, “We are part of a major change in health care that we haven’t seen since the beginning of the 20th century.” But like a novel treatment for a chronic ailment, the cure for America’s bloated hospital industry will need careful monitoring for side-effects.