If you follow your local healthcare marketplace even superficially you have probably noticed that everybody is merging with everybody else. Hospitals, physician groups, and even insurance providers are combining themselves in various ways, ostensibly for the purposes of either making money or helping people, or both. The Affordable Care Act has had something to do with this by agreeing to pay these groups in specific ways, depending on a set of performance measures. There are three broad categories of such groups: Physician Quality Reporting System (PQRS), Group Practice Reporting Option (GPRO), and Accountable Care Organization (ACO).
ACO’s in particular have gotten a lot of attention because the payment system rewards cost-savings and makes the group pay for cost overruns. For example, medicare will pay $X to ACO Y for all their medicare patients. If the total cost for care of all the medicare patients in ACO Y is lower than $X, the members of the ACO keep the change. If the total cost is higher, the members lose money. In order to prevent wily hospital CEO’s from skimping on care and pocketing the dollars, 33 performance measures are followed to ensure care is adequate. Forgive me if all of this is review. I’m getting to my point.
Last Friday the government released performance numbers for five of these measures for 141 ACOs in 2012. The five they chose were, essentially, the easiest to understand and the least controversial. Four deal with diabetes and one with vascular disease. Here are the measures:
1. Controlling blood sugar levels in patients with diabetes
2. Controlling blood pressure in patients with diabetes
3. Ensuring that patients with diabetes do not smoke
4. Prescribing aspirin to patients with diabetes
5. Use of angiotensin-converting inhibitors (ACE-I) or angiotensin receptor blockers (ARB) in patients with diabetes and weakened left ventricles.
According to the Kaiser Family Foundation analysis, ACO’s accomplished these 5 measures satisfactorily 65-75% of the time. OK, not bad. The groups varied widely, however, from 9% on some measures to 97%. The other two types of group payment systems, PQRS and GPRO, did a little better. I’ve been searching around but I can’t find any data on how all individual groups within the ACOs did on these measures before they joined the ACO. That would be nice to know.
The thing is, I’m not sure why consumers need this information, at least on an individual basis. You see, patients don’t choose a specific ACO. Chances are you are in one and you don’t even know. You can’t shop around for an ACO, or a PQRS, or a GPRO. You the patient don’t know how your personal doctor fares on these metrics. What is important to know is how your doctor is getting paid, or not. It’s important because, if you look at those quality measures above, you notice that one of them is a personal behavior that has little to do with your doctor (smoking), and two others require significant patient cooperation (controlling blood sugar and blood pressure). So, in very real way, the behavior of you the patient determines how much the doctor gets paid. Imagine if a group of, say, plumbers got together and persuaded 5,000 customers to pool their money and pay them a set rate for any plumbing problems that occurred in a given year. Say 100 or so of those customers hate all plumbers. Or are just really irresponsible. Those people could, with their behavior (clogging drains, putting hair in the toilet, letting the pipes freeze, etc.), decrease the pay for all the plumbers in the group. Plumbers are smarter than doctors and would never put up with pay being dependent on someone else’s behavior. That’s what your doctor faces. Just so you know.