With the reelection of President Obama, full enactment of the Patient Protection and Affordable Care Act is all but certain. Part of that legislation is the establishment of Accountable Care Organizations (ACOs). These large networks require a minimum of 5,000 Medicare patients, and will assume the total costs for their care in many cases. Over 140 ACOs are already established with over 130,000 physicians and 2.2 million beneficiaries.1 Much of the broad legislation governing ACOs has yet to be converted to specific regulations, which will vary between states. Because so much of this change has yet to be decided, and large systems will have to rapidly adapt, ACOs may become a sudden order of business for family medicine program directors.
ACOs are a model of shared risk for costs and savings of a defined population. The more patients a network has, the more easily they can spread the costs of expensive care of the relatively few. In the ACO model, hospitals will shift from revenue centers to cost centers. ACOs have the potential to shift systems to embrace wellness rather than reactive illness care. In the future, we may get reports on how much our patients cost the system, rather than how much revenue we generated with our level-4 visits, inpatient billing, and procedures. Many systems will need to increase their primary care workforce as more patients have health coverage, and systems shift their emphasis to outpatient and preventive care.
Insurance and payment reforms are the first 2 steps in health care reform. The third phase is delivery system reform.1 A need to educate those making ACO formation decisions will exist, regarding the value of family medicine residency programs to ACO networks. One of the fundamental objectives of the National Institute of Program Director Development (NIPDD) training is to understand the worth of your program; in the world of ACOs, our 2 principal strengths to promote will be cost-effective care and workforce generation.
To truly provide population health care (rather than just those who come to see us) will require a fundamental shift in perspective for our systems, and most of us as well. Many of us will need to learn new skills; we will need to strongly advocate for resources such as case managers, chronic disease registries, and searchable electronic health records to provide high quality, cost-effective health care to a population. We also need to advocate for payment reforms that truly reflect our value to our systems. If we are not involved in the early formation and leadership of ACOs, we risk maintaining the status quo of huge payment disparities between procedure-based specialists and diverse primary care practices. These disparities discourage future medical students from entering primary care, which eventually will hurt all of our patients.
Residency education about cost-effective care is optimized if the system can provide each resident with clinical quality and cost data on their own panel of patients, rather than having them subsumed under the faculty patient panel. We need to advocate for not just teaching about quality improvement, but doing it in our residency practices.
Family medicine has a long and celebrated history of advocating for our patients. With the formation of ACOs, there is a moral imperative that we advocate for systems that reflect our values as a specialty. In the next few months, many decisions will be made that will affect both process values (the rules that govern decision-making processes such as transparency, accountability, and participation) and content values (clinical effectiveness, cost-effectiveness, justice/equality, and autonomy).2 We all need to ensure that family medicine has a voice at the table, and that we are proud of the end result. After all, the ACOs created in the next few months will be the ones our graduates will be practicing in for the foreseeable future.
- © 2013 Annals of Family Medicine, Inc.
