ACOs and Population Health – It’s the Denominator, Stupid !

ACOs or Accountable Care Organizations were created by the health reform legislation proposed by President Obama and passed by the legislature one year ago. They are the Nation’s new hope in reorganizing the financing (and, it is hoped, the delivery) of health care to support improved outcomes. Patients are not required to belong to an ACO and the ACO does not restrict the patient’s access to any caregiver they choose. The ACO is, however, incentivized financially to help the patient organize their health care to achieve a better outcome and thus, save the health care system money. The money saved, in one model being proposed, is then shared between the payer (the insurance company or government in the majority of cases) and the provider (the ACO).

Now that the Medicare regulations have been proposed (by CMS on 3-31-11) it is clear that the attribution method used to assign patients to an ACO does nothing to encourage a health care provider to reach out to their community to engage new patients. To be in a particular ACO, the patient has to get the plurality of their care with a provider in that ACO. To be paid a premium for that patient’s care, the provider must focus on optimizing the care of that patient – definitely a good thing to do.

But if I want to improve the outcomes for people with diabetes in the community, I have to outreach to the community, focusing not just on the patients who are already getting a plurality of care from me, their doctor, but rather on the at-risk patients, patients lost to follow-up, and patients who have scattered and disorganized care – using emergency rooms as their family doctor. Only by reaching those patients who are not regularly in the care of a given provider can we achieve better outcomes at a community level.

The problem is not unique to ACOs. All quality improvement programs, rewards for doctors to improve the care of their patients and all quality recognition programs for providers focus on improving the care of patients we already see. This is surely important as doctors everywhere give suboptimal care – usually missing needed preventive health care interventions and focusing on acute care needs. But to improve population health we must reach out to those who do not have a regular source of primary health care.

To accomplish this we need to change the entire process of quality reporting and add some community based outcome measures into the expanding list of measures that are used to evaluate the work of physicians. As we move our patients into ACOs, we must be sure to simultaneously increase our focus outside of our practices and make sure that we engage people not currently in organized primary care systems.

As we develop quality reports we should run them all in two ways. First, we should run them to assess the quality of care we are giving to the patients who have committed their care to us – those who, for example, have been to see us at least twice in the past year. Second, we should run our quality reports using, as a denominator, any patient who has ever been into our health center with the condition being evaluated. This will measure how well we do with patient engagement, how well we are doing with outreach to those lost to follow-up and will encourage patients who have dropped out of care, to re-engage. Even if we do not have the resources to do frank community outreach, efforts to reach this group of patients will help to address those who are not in care and will help build our patient base as well. ACOs need to develop a mechanism to support this type of work in our practices, lest they just become another reward for caring for those who are already committed to a source of care.