Accountable Care Organizations: Implications for Cancer-Related Quality Care and Spending

Caroline Helwick

August 2011, Vol 2, No 5 - Health Policy


David Miller, MD, MPH

Chicago, IL—Accountable care organizations (ACOs) are a prominent part of the Patient Protection and Affordable Care Act (ACA), better known as the healthcare reform. ACOs are believed to hold the potential for addressing variation in quality and costs of cancer care, but their impact will depend on buy-in and leadership among oncologists, according to David Miller, MD, MPH, a urologic surgeon and health services researcher at the University of Michigan, Ann Arbor. He addressed this topic during the recent annual meeting of the American Society of Clinical Oncologists.

“There is a lot of uncertainty on this topic,” noted Dr Miller. “The story is yet to be told.” Section 3022 of the ACA established a Medicare Shared- Savings Program that allows for ACOs to participate in Medicare. The program is slated to be implemented by January 2012, but full details are just emerging.

Quality Measures Focus of ACOs

An ACO is a large group of pro – viders that accepts responsibility for the quality and cost of care provided to a population of patients. This can be in the form of physician group practices, networks of individual or group practices, joint ventures between physician organizations and hospitals, or hospitals that employ ACO physicians.

The ACO has explicit mechanisms for receiving and distributing shared savings, repaying shared losses, and performing quality measurements. “This sounds like the HMO [health maintenance organization] of the ‘90s,” Dr Miller observed, “but with quality measures and opportunities for shared savings.” Of course, the mechanisms for the proposed savings are very complex, he added.

There are 65 proposed measures for reporting related to quality of care in the following 5 domains:

  • Patient/caregiver experience
  • Care coordination
  • Patient safety
  • Preventive health
  • At-risk population and frail elderly health.

Breast and colorectal cancer screenings have strong emphasis. Performance is measured via claims, surveys, and the use of new data collection tools.

High Expectations

Approximately 75 to 150 ACOs are expected to be in place over the next 3 years. This means 1.5 million to 4 million Medicare beneficiaries will be covered through ACOs, with a projected savings of $510 million over the 3-year period, according to Dr Miller.

“But, there are mixed emotions about ACOs,” he added, as exemplified by 2 recent perspectives in the New England Journal of Medicine (Haywood TT, Kosel KC. N Engl J Med. 2011;364:e27; Ginsburg PB. N Engl J Med. 2011;364:2085-2086) that describe the controversies and criticism, much of it doubting the potential for costsavings.

“On the other hand, some say we need to do even more,” Dr Miller acknowledged. This has led to a “virtual ACO economy” aimed at fine-tuning how the whole process will be engineered and fulfilled, he said.

ACOs May Curb Variation in Care

ACOs might be most useful, he maintained, by reducing variation in quality and cost in the “3 big-ticket areas” of treatment decision-making and therapeutic intervention, identification and management of side effects, and the delivery of end-of-life palliative care. Studies have demonstrated significant variation by specialty, geographic area, hospital, and race/ethnicity.

Variation in care is relevant to ACOs for several reasons. Variation in quality suggests basic problems with cancer care delivery: overtreatment, undertreatment, or both. It also suggests the need for evidence-based medicine, quality measurements, and shared decision-making.

Variation in costs suggests there is a place for business in setting quality and eliminating waste, for example, by improving coordination across care settings, Dr Miller said.

ACOs are relevant in this setting, he noted, because “both hospitals and physicians would have ‘skin in the game’ with respect to optimizing efficiency of cancer care,” but there is “major work ahead in defining optimally efficient practices,” he added.

“We need to define what constitutes efficient care in oncology, because a lot of money is at stake,” Dr Miller emphasized.

The Challenges of ACOs for Oncology

The challenges in developing ACOs for cancer care primarily reflect that cancer is so complex, encompassing a variety of specialists (in separate silos), surgeries, imaging, and medications. As such, cancer-related costs are substantial, especially in the initial diagnostic period, but there are also continuing costs pertaining to disease recurrence and end-of-life patient care.

Although medical oncologists usually serve as the primary provider of care for cancer patients, primary care providers (PCPs)—who are less in – formed about cancer—are sometimes tapped for this role, at least after the initial treatment period. “The challenge for PCPs to manage that care and ensure high quality and low cost is monumental,” Dr Miller suggested.

“We feel the locus of control is best kept in the oncology field, he said.” There are other “pragmatic issues,” he added. For example, oncologists may be unwilling to participate in an ACO led by a small hospital or primary care group. “The truth is, oncologists are unlikely to participate in an ACO voluntarily if it is led by a primary care group or small hospital,” Dr Miller said. “And if oncologists are not participating, there will be a huge cost center left outside of the scope of this policy lever. It will be hard to achieve savings goals without the involvement of cancer care.”

Questions for Oncologists

“There is no question that ACOs hold some promise, and we should all be considering how this and other policy reforms could be used to improve patient care,” Dr Miller said.

However, he said, there are practical issues to be resolved:

  • Can oncology specialists form their own ACOs?
  • Will oncologists and cancer hospitals function as “free agents” that compete for referrals based on cost and quality?
  • How can quality of cancer care best be measured within an ACO?
  • Should oncologists be able to “lead within their ACOs,” will this translate into cost-savings?

Dr Miller said that “it feels good, but whether it achieves cost-savings is unknown.”