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Are ACOs Ignoring Surgeons?

Top priority goes to managing chronic conditions and reducing readmissions

According to a report from the Kaiser Family Foundation, accountable care organizations (ACOs) have paid little attention to surgery in the early years of the Medicare program, choosing instead to focus on managing chronic conditions and on reducing hospital readmissions.

Those were the findings of a case study and survey published in Health Affairs. The authors conducted case studies at four ACOs in 2012 and sent a survey to all 59 Medicare ACOs in the first year of the program, with 30 responding.

Surgery represents 50% of hospital expenditures, and “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,” the authors write.

They found that surgery was not part of the strategic plan for the first year at any of the case-study ACOs. Moreover, 86% of survey respondents rated the priority of reducing unnecessary surgery as “medium,” “low,” or “very low.”

Generally, ACOs are more interested in reducing expensive hospital admissions by managing the care of patients with chronic illnesses, such as diabetes, the survey found. In addition, it’s difficult for ACOs to figure out how to share savings with specialists, such as surgeons. With primary care physicians, it’s relatively easy to figure out their share of the ACO’s savings by factoring in the number of patients they have seen. Specialists, on the other hand, may treat only a handful of patients each week.

The authors of the Health Affairs article also found that the amount of possible shared savings for surgeons would be smaller than the potential revenues they could generate from additional surgeries. Therefore, changing referral patterns to those surgeons might actually be a more effective way to manage the cost and quality of the care they provide.

“A surgeon who was left out of an ACO, or asked to leave an ACO because of poor performance, would risk losing a referral stream from primary care physicians who participated in the organization,” they wrote.

The fact is, ACOs are probably more effective at rewarding providers for reducing avoidable care than for making unavoidable care more efficient. In other words, ACOs may be good at reducing the number of surgeries, but not at making the surgeries that have to happen more efficient. For that reason, the bundled payment model, in which providers receive a set amount of money to handle an episode of care, may be a more direct way to reward surgeons who are practicing efficiently.

Source: Kaiser Health News; June 5, 2014.

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