Anesthesiology and Accountable Care Organizations: What impact will ACOs have on anesthesia delivery in hospitals and ambulatory surgical centers?
What are Accountable Care Organizations (ACOs)?
“Accountable Care Organization” (ACO) is a term attributed to Dr. Elliott Fisher of Dartmouth Medical School. An ACO is a model of healthcare delivery aimed at improving quality while decreasing costs. ACOs are a key component of the Medicare Shared Savings Program, contained within the Affordable Health Care Act passed in 2010 and upheld by the Supreme Court earlier this year. ACOs provide the mechanism for “shared savings”; if physicians organized within ACOs meet specified quality standards and decrease healthcare costs, those cost savings are ‘shared’ between the physicians and the Centers for Medicare and Medicaid Services (CMS).
The American Society of Anesthesiologists (ASA) has compiled an extensive set of frequently asked questions regarding ACOs. The ASA has expressed a number of concerns about the legislation, including “an overwhelming focus on chronic disease management [and] limited attention to the role of specialists in improving quality and controlling costs”.
What is the role of anesthesiologists in the ACO?
ACOs are vertically structured care organizations, typically consisting of primary care physicians, at least one hospital and specialists. This integrated healthcare team is responsible for working together to cost-effectively improve the health of their designated patient population. While anesthesiologists and other specialists are not expressly prohibited from forming ACOs, certain eligibility requirements make it unlikely that they would be the key players. These include the stipulationthat ACOs includea sufficient number of primary care physicians to care for a minimum of 5000 assigned. Anesthesiologists in smaller towns and more remote regions may find that no primary care practices or hospitals in their region have a large enough patient base to establish an ACO. In more populous areas, many anesthesiologists may find themselves de facto members of an ACO formed by the hospital or hospitals they serve.
However, while anesthesiologists may be unlikely to play a direct role in forming ACOs, they do have a large impact on the two essential outcome measures of ACO success: cost containment and quality of care. At a meeting in late 2010 with CMS administrator Don Berwick, MD, American Society of Anesthesiology leadership addressed the role of anesthesiologists in ACOs. First Vice President of the ASA John Zerwas, MDstated “We have a unique opportunity to lead because we care for patients through the entire peri-operative period, from admission through discharge. Eighty percent of the hospital costs come during the peri-operative period and anesthesiologists, who consistently manage the care of patients during this period, have the greatest opportunity to improve outcomes and lower costs.”
How will participation in ACOsaffect the delivery of anesthesia services in the hospital and ambulatory care setting?
• Increased responsibility for reporting on quality measures in anesthesia care
To share in the savings generated by decreased healthcare costs, the ACO must meet a number of quality measures under the broad categories of patient/caregiver experience, care coordination, patient safety, preventative health and at risk populations. Anesthesiologists have a particular role to play in the patient safety category, which includes events such as central line and catheter associated infections and postoperative sepsis. Many anesthesia practices already have mechanisms in place for documenting such occurrences and reporting them via the Medicare Physician Quality Reporting System (PQRS) and/or the National Anesthesia Clinical Outcomes Registry (NACOR) and Multicenter Perioperative Outcomes Group (MPOG). To meet the requirements of the new legislation, fully transparent reporting of all such events will be mandatory.
• Increased utilization and integration of Anesthesia Information Management Systems (AIMS)
One of the components of the ACO rule is financial incentives to groups that demonstrate meaningful use of the electronic health record. The American Society of Anesthesiologists is encouraging anesthesiologists to participate in this incentive program, typically by the utilization of anesthesia information management systems (AIMS) fully integrated with the existing hospital or group information system. An AIMS provides for automated data collection from the anesthesia machine and patient monitors, as well as manually entered data regarding medication administration, airway management and other clinical parameters. In addition to meeting requirements for the ACO, an AIMS has multiple benefits for the anesthesia group, including a streamlined interface for reporting clinical outcomes to national registries and improvements in anesthesia practice management through the tracking of procedure mix and billing efficiency.
• Increased responsibility for managing anesthesia patients throughout the entire care episode
In an ACO, anesthesiologists will need to demonstrate their value in terms of reductions in patient care costs to ensure their participation in any shared savings. In an open letter to CMS administrator Donald Berwick, MD, President of the American Society of Anesthesiologists, Mark Warner, MD delineated the means by which anesthesiologists could deliver savings throughout the entire care episode:
“shared savings would be derived… through pre-operative evaluations performed in anesthesiologist-run Pre-Anesthesia Testing (PAT) clinics, as well as reduced hospital lengths of stay and hospital readmissions arising from 1) selection of appropriate candidates for surgery, including interventions with those who are highly unlikely to benefit, 2) identification of optimal timing for surgical interventions, to avoid rescheduling, 3) reduction of complications such as surgical or catheter-related infections, poor perioperative glycemic control, and postoperative nausea and vomiting that increase length of stay or necessitate admission following outpatient surgery, and 4) improved perioperative management of pain and anxiety to ensure the best possible patient care experience.” [American Anesthesia Society Responds to Accountable Care Organization Proposed Rule]
Anesthesiologists typically interact with surgeons, who are well aware of the value anesthesiologists add to perioperative care. However, under an ACO, anesthesiologists will need to develop means of tracking and recording their contribution to healthcare savings, to better communicate the value of anesthesia services to the primary care physicians heading the ACO. The anesthesia practice’s allotment of any shared-savings bonus from Medicare will depend solely on successful negotiation with the ACO leadership.
Views expressed are the author’s and may not necessarily be shared by Xenon Health, LLC. Nothing in the article should be construed as legal or medical advice.
