Where do Pathologists fit into Accountable Care Organizations? – Part 4

| January 24, 2011

The following post was submitted by Dr. Ben Calhoun, a practicing pathologist in Charlotte, NC. This is Ben's fourth submission in a continuing series on trying to answer the question "Where do Pathologists fit into Accountable Care Organizations?"

By now, almost everyone knows that the Center for Medicare and Medicaid Services (CMS) is drafting regulations that will guide implementation of the ACO program, scheduled to begin January 1, 2012.  What will the regulations look like?  For that matter, what will the often discussed (but rarely seen in the wild) Accountable Care Organizations (ACOs) look like?  Of course, we pathologists have to continue to ask:  Where do pathologists fit into ACOs?

For an excellent overview of the available data from the Medicare Physician Group Practice (PGP) demonstration project, I recommend the recent commentary in the New England Journal of Medicine by John K. Iglehart (a national correspondent for the Journal).   

He makes several points that I found interesting:

The project followed defined "quality goals, most of which were process measures related to coronary artery disease, diabetes, heart failure, hypertension, and preventive care."  I personally have not come across very many articles on ACOs that focus on oncology, and I assume that's where most surgical pathologists making tumor diagnoses will get involved.

Many pathologists and pathology practices either are formally part of an Integrated Delivery Network (IDN) or essentially function as part of an IDN through their group practice contract.  We should consider the fact that "No performance payments were earned by the five PGPs that are part of integrated delivery systems (systems that include hospital ownership but are not affiliated with academic medical centers) or by the physician network (Middlesex) that is sponsored by a hospital affiliate."

Since most pathologists mainly work in hospitals (as opposed to private or purely commercial laboratories), we should note that "The majority of the savings at all sites occurred in outpatient, not inpatient, services. [analysts] hypothesized that the presence of a hospital was “a potential deterrent to achieving savings . . . since these systems may be unable to reduce avoidable admissions or use lower cost care substitutes without affecting their inpatient revenue.” That's right, the hospital is a potential deterrent to achieving savings.

Patients move around and switch doctors, and the issue of how patients (and the expense of their care) are attributed to ACOs is becoming a big deal:  "Patients were attributed retrospectively to a PGP if they received more of their primary care from the group’s physicians than from anyone else. These details of attribution — whether, when, and how beneficiaries are informed that they’re part of an ACO and what data on the patient population will be provided to the ACO by the CMS — have provoked intense debate."

Given the current state of our federal and state budgets, more drastic reductions in reimbursement may be required to achieve the desired reductions in spending: "……as it attempts to reduce the vast budget deficit, Congress may need to take more sweeping steps to slow the growth in Medicare spending long before the ACO model can prove whether it is up to meeting these challenges."

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Category: Pathology News

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