Urologists foresee possible merits, drawbacks with accountable care organizations

Since passage of the Affordable Care Act, more than 250 accountable care organizations (ACOs) have been established, the Centers for Medicare & Medicaid Services reported last month. ACOs-groups of health care providers who come together voluntarily to provide coordinated, high-quality care to Medicare patients-are part of the federal government’s effort to improve patient care while decreasing health care costs.

Urology Times talked to urologists around the country about their current involvement in an ACO, if any, or if they had started preparing for an ACO future.

We found that even though ACOs are becoming an established part of the health care landscape (some 5% of Medicare patients are already involved in an ACO), urologists still have many unanswered questions. Information on how the programs will work is lacking, they say, even at institutions following ACO policies.

Urologists have mixed feelings about how well ACOs will achieve their goals and how they will impact reimbursement for the specialty of urology.

Jamie Lowe, MD, practices in Glenwood Springs, CO. Her group’s physicians decided to join a hospital to give themselves a working relationship before ACOs were formed.

“I don’t know of anyone here in Colorado actually looking at accountable care organizations; we’re preparing for them although we haven’t really looked at them,” Dr. Lowe said.

“We are in a unique situation because we are now hospital based, and we’re still able to see patients at other hospitals in the area.”

J. Stephen Jones, MD, chief of surgical operations at Cleveland Clinic’s Fairview Hospital, says Dr. Lowe’s location may provide a reprieve for a while until other larger hospital systems and ACOs get more of the details worked out.

President Obama cited Cleveland Clinic as a role model for providing excellent care while keeping costs down, but it has not signed on as an official ACO with CMS. Cleveland Clinic is conducting various pilots within its health system to help it decide whether to pursue ACO status.

Current focus is on primary care

Dr. Jones says so far, most of the system is centered on the primary care level rather than on specialty care.

“They are really looking at disease management, so urology’s primary focus has probably been to keep our eyes open because we certainly want to be prepared for how this develops and also to support our primary care colleagues,” Dr. Jones said.

“Ultimately, specialties will be part of it, but right now I think the payers, including the government, recognize that the big opportunity for disease management is to impact primary care and chronic diseases such as obesity and diabetic care. I believe those conditions are supposed to be related directly, or indirectly, to about 20% of health care costs. If they can begin to control those conditions, with those large number of patients, that would probably be a big lever on driving the accountable care concept.”

Urologists expressed several concerns about how their practices will be impacted by ACOs. Paul Brower, MD, in Laguna Hills, CA,

has spoken to groups about the implementation of ACOs. He belongs to an independent practice association (IPA), which is participating in CMS’s Innovation Pioneer ACO experiment.

“It’s all about financial risk and cost sharing and sharing savings at the end. That’s the whole idea of the experiment,” Dr. Brower said. “Being in an IPA that deals with about 125,000 lives, we’ve adapted to a capitated model since about 1992. We have a lot of experience dealing with seniors. The idea is for Medicare to look at all of these experiments and determine which ones work and which don’t, then figure out why they work, and translate that across the country to all Medicare and Medicaid patients.

“In some areas of California, private payers are so concerned about being rendered irrelevant that they’re desperate to sign up these narrow networks of providers. These narrow networks are a chosen panel of providers, including hospital systems, primary care physicians, and specialists. They’re going to the employers and offering, not only a leveling of the dollars, but actually giving reductions in their premiums in some cases if they enroll their employees in these narrow networks that have proven quality and economic efficiency. Some ACOs and narrow networks will be able to reduce costs and others won’t. The employer, payers, and providers, if successful, will share savings.”

An uncertain future

Although the urologists who spoke to Urology Times are still waiting for clarification of exactly how ACOs will affect them, they have different expectations of what they may be dealing with in the next few years.

In Tucson, AZ, Joel Funk, MD, said, “Being in an academic center, I’m kind of out of the loop as far as the logistics and the finances go. There’ve been some high-level discussions here, but that’s above my pay grade. I don’t know that it’s actually trickled down to those of us who are boots-on-the-ground people in regards to how it’s going to affect our day-to-day practice.

“The model in which I practice is a little different than most community urologists in that I am a salaried, academic guy. What comes in as a facilities fee and what comes in as a professional fee for procedures doesn’t really affect me directly. It ­certainly affects the institution, but the breakdown doesn’t have a huge impact on my take-home income.”

As a community urologist, Dr. Lowe is concerned about how urologists may be compensated when they provide an ancillary service for conditions that are not a urologic diagnosis.

“One example of my concern is, what happens when a patient comes in with something like a hip fracture and goes into urinary retention afterwards? We’re involved in that and they need a TURP afterward, they may need rehab, so everyone gets a little cut of that hip fracture diagnosis. How are urologists in that scenario going to fare? I’m afraid we’d be pretty low on the list,” she said.

Financial risk enters the equation

Dr. Brower says the details of how urologists will do when they are in an ACO will depend on what is negotiated.

“We have over 100,000 lives under capitation. But because we have financial risk, we do a good job managing these patients; that translates all the way through the way we care for them and all of our patients,” Dr. Brower explained. “We are confident that the efficiencies we have learned will allow us to take contracts involving bundled fees and global risk.

“I tell everybody that this is a zero-sum game. There will not be any new health care dollars; it’s just a matter of figuring out who’s going to get what,” he said.

“I would argue that one positive thing about urology is that we account for less than 2% of the total dollars. So our goal has been to stay off the radar and say, ‘Just send us the money and we will provide excellent and efficient care for your patients and take financial risk alongside of you.’ ”

Working in a large institution, Cleveland Clinic’s Dr. Jones believes, may provide some advantages for specialists.

“The beauty of our system is that we have the luxury of being able to take a holistic approach to most patients, and if indeed they need something major, which urology usually does, the system will serve that well,” he said.

“By the same token, if we can reduce morbidity of many of common chronic diseases, and if in all, that is a decrease in the need for certain services, our system can handle that so that it’s not anything bad for the urologist. Having the right incentives in place in our system has been one of the reasons we’ve been able to be in the forefront of many of these concepts over the last few decades.”

Similar to the Kaiser system?

Gregory Rosenblatt, MD, in Hillsboro, OR, says he hasn’t heard much about ACOs at the hospital where he works but his past experience leads him to believe ACOs can work.

“When I trained, I came up through the Kaiser system. To me, that is the epitome of the ACO, where there are guidelines for when referrals take place,” Dr. Rosenblatt said. “It definitely was more integrated and cost ­saving, and I didn’t feel shortchanged as a urologist.”

The results of ACO formations do generate very different forecasts for the future. In recent months, community-based urologists who practice outside the sphere of large medical centers have told Urology Times they don’t know what their future holds because they don’t have hospital systems with which to align themselves. Two of this month’s urologists see those futures differently.

Dr. Brower said he thinks all physicians will be absorbed into ACOs in a matter of years.

“They will all be part of a large network,” he said. “I don’t expect there to be a single hospital or a single physician continuing in solo practice or unaligned 5 years from now.”

Dr. Jones has a different take on those outlying specialists.

“I think they will be the least affected,” he predicted. “Those urologists may be less vulnerable because their patients will need care, and those urologists will be in a position to provide those services.”

Previous experience also influences the physicians’ expectations for the quality of health care under the ACOs.

“I think ACOs can improve patient care,” said Dr. Rosenblatt. “Ultimately, patients get the right treatment either way, but I think we overtreat sometimes. A lot of referrals probably don’t need to be made. One example is microhematuria, when primary care physicians refer patients based on dipstick analysis only.

“At Kaiser, they have guidelines. Doctors have to have a microscopic urinalysis with at least a minimum number of red blood cells to meet the criteria to be referred on. That’s just one example.”

Dr. Lowe is concerned about the bureaucracy the ACO system might engender.

“Being involved with a hospital, every year the level of bureaucracy increases,” Dr. Lowe observed. “The number of additional meetings we are required to go to, with the additional things we have to do, the documents we have to fill out in order to be part of the hospital just go up and up.

“As more people get involved, I worry about that and how it will affect care.”

Dr. Jones says there is no real basis on which to predict the outcome of ACOs.

“This is a very large social experiment,” he said. “There’s no doubt the goals are laudable and the intent is honorable as well, both on the part of Medicare and also on the part of organizations that are participating.

“But when you go into an experiment like this, you really don’t know if it’s truly going to have the impact of reducing cost or improving care. As an eternal optimist, I’m very hopeful, but we really don’t know the answer.”UT

Karen Nash is a medical reporter and media consultant based in Sioux Falls, SD.