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Will ACO implementation improve patient health, or just cut costs?

Accountable care organizations are supposed to cut health care costs. Experts wonder if ACO technology and physician incentives can also make patients more responsible.

BOSTON -- The Partners Healthcare Connected Health Symposium 2011 showcased demonstrations of technology's incredible potential for extending health care into the patient's home. Among the demos was hardware -- such as a talking robot with cameras connecting patients and physicians -- and software, including an array of PC and smartphone apps that can help caregivers and loved ones track elderly patients' whereabouts, appointments and medication adherence.

Coincidentally, on a conference call hundreds of miles away, CMS unveiled its final rule for accountable care organization (ACO) implementation. This will keep health care CIOs busy with data tracking, analytics and reporting so their organizations can reap the shared savings that ACOs theoretically could bring. However, ACO implementation could also put that end-user technology to work in hopes of cutting costs by making patient care more interactive -- for example, by solving elderly and chronic disease patients' minor health issues before they escalate into crises requiring hospital admissions.

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Much talk from the stage and in the halls centered on patient accountability -- specifically, whether physicians should be held accountable for bad health choices their patients make. Added to that was the application of the technologies on display. Could tech motivate patients to make healthy choices in the ACO scenarios, knowing that health care practitioners would be keeping a closer eye on their habits? What about the diabetic patient who would be sending constant blood-glucose readings over a smartphone?

"In principle, technological advances could be cost-decreasing in health care," even though in general they tend to be cost-increasing, speaker Jonathan Gruber, an MIT economist specializing in health care, told after a session debating strategies to improve patient accountability.

"It's just that [vendor] incentives are not set up for that to happen," he said. "There's just no incentive in the system to develop those right now. So the hope would be that things like accountable care organizations would provide incentives for technology to be used for good, rather than for cost increases."

Technologies connecting patients at home with their caregivers is necessary but not sufficient, said George Arnold, program manager, Health of New Zealand Trade and Enterprise. His agency is charged with building the island nation's health IT infrastructure and developing a new care coordination program for chronic disease patients.

"Clinicians are always going to have a duty of care, but we need to change the balance," Arnold said. "Right now the burden is exclusively on the physician's shoulders. It needs to shift to sit on the patient's shoulders as well. Just dumping technology on a patient is not enough."

That, he added, can be accomplished with policies stating clearly that patients are responsible for their own health. Such policies could include incentives, along with the technological tools that can help them realize the rewards.

Blue Cross' private program shows ACO implementation model can work

In the session debating the potential of ACOs, Dana Safran, senior vice president at Blue Cross Blue Shield of Massachusetts, said her plan's Alternative Quality Contract (AQC) -- which tracks several quality measures and pays bonuses based on performance -- was bullish on the ACO model. She based her opinion on the quality improvements seen in the first year of the AQC program, including better adherence to cancer screening, well-patient visit and chronic disease care quality metrics. More than 2,000 physicians participate in the program, covering about 40% of the payer's 430,000 patients.

Others weren't so sanguine. Timothy Ferris, M.D., medical director, Massachusetts General Physicians Organization, said ACOs remind him of the failed concept of managed-care organizations of the 1990s. Patients rejected the idea because they felt it restricted access to health care, and physicians disliked the idea so much that patient perception changed as well. Ferris feels that patients will need their own set of incentives to become truly accountable. Once patients are engaged, though, there will be potential to realize the cost savings that ACO implementation strives to achieve.

Once patients are engaged, there will be potential to realize the cost savings that ACO implementation strives to achieve.

In the debate, Gruber noted that the only two years since World War II in which health care cost increases didn't outpace inflation were during the 1990s, in the peak of the managed-care era. While patients ultimately rejected them, they did actually reduce costs. In a similar way, ACO implementation will likely require patients to receive less intensive treatment than they get today -- but they can only succeed, Gruber said, if it's "less intensive treatment in a way that does not harm their health."

Increasing accountability may require patients to pay more for their care as well as their insurance, he continued. That trend already is being driven by employers, who can afford to pay a smaller and smaller share of premiums. Workers, Gruber concluded, are already demanding more high-deductible health insurance plans. "I think patients will then live within those constraints."

ACO implementation will require better care coordination

All of the speakers -- as well as physicians in the audience posing questions to them -- agreed that the keys to cutting costs in health care include increasing communication with patients and cutting down on wasted treatments and tests through better communication between care providers.

As Safran pointed out, that's not just a theory. AQC participants are cutting down on costs by policing their own care coordination. Quality managers at hospitals, for example, are making sure patient lab results get to primary care providers faster so the primary docs don't order duplicate tests.

"Now it matters to them what happens after the patient leaves. These institutions are now working very hard to follow up on patients like this," Safran said, up to and including home visits to patients they identify as carrying a high risk of readmission.

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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