ACO and HMO: HMO redo or something new?

I have covered this topic before but I came across an article that stimulated by thinking again.

It has been said that ACOs are really the new HMOs. HMOs in the 1990 were an experiment to put ‘risk and reward in the same bucket.” Much like integrated capitation, the idea is to let those that save money, while still delivering great quality care, benefit from their innovations.

This was the thinking behind the Affordable Care Act, which seeks to re-align risk and reward. It also, possibly unfortunately, makes Provider power even more concentrated. Maybe that’s good, maybe that’s bad.

A recent analysis of healthcare costs as a % of GDP came out in the New England Journal of Medicine. One of the questions we want to answer is where the healthcare costs will be a decade from now based on changes today. Typical projections run that in a decade or so, that 20% of the US GDP will be spent on healthcare (all private and public expenditures). This is based on projects from the last 2 years worth of data, which have shown lower health care growth rates than the past 20. The past 2 years of healthcare growth rates have been thoughtfully reviewed and it has been determined that these growth rates in the past 2 years are not representative of growth rates that we are likely to see in the next decade or two.

This NJEM article, published May 22, 2013, The Gross Domestic Product and Health Care Spending (Victor Fuchs, PhD), suggests that the growth rate that should be used is probably the long term growth rate, that recent changes in the growth rate are one-time events and that using 2 year growth rates is typically a bad idea anyway. The articles also describes how the growth rates were greatly reduced, cut in 1/2, when HMOs came out. HMOs rationed care. It is generally thought that most people want “all you can drink” healthcare for their “buffer” prices and this is the reason that HMOs were given the boot by consumers. Victor thinks that if you use historical growth rates, then the share of GDP for healthcare grows to 30%. That’s huge.

So if ACOs are really HMOs reborn, wouldn’t that be a good thing? Its probably a good thing to think it through a bit to see if such a top-level thought holds water. First we’ll recognize that the ACOs and concentration of power into Proivders (the Act gives enormous emphasis on hospitals) which possibly leads to verticalization is not necessarily bad, at least in business circles. And combining risk and reward to get incentives right, is also probably not a bad thing.

But there are other factors. We will also assume that that Americans will not engage in more healthy lifestyles since changing people’s behaviors towards the healthy has not really worked nor probably will ever work without significant economic rewards. And we will assume that Americans want choice and do not like being told where to get their healthcare services (especially since care is so uneven).

If normal competition were at work, then we would expect that verticalization and centralizing risk & reward should all be good. We should expect to see declining prices and improving outcomes.

But when we look at the healthcare spectrum, we see some of the largest improvements in outcomes results from drugs and medical devices. We do not see large improvements in care based on “processes” inside of hospitals. While some hospitals do indeed work on Six-Sigma type continuous process improvements and show great results, they are inconsistently used and are not a source of large-scale productivity increases.

So we have not seen that hospitals are capable of being managed to reduce their costs and improve outcomes to any significant degree. In fact, most innovation in the hospital community is around centralization, getting big to have the scale. But we need to ask ourselves if whether hospitals becoming large lowers cost and improves outcomes, or does it just allow more fixed cost (beds) to be spread out over a large surface area threrby reducing per unit costs but not reducing costs? The ACOs models of having a minimum of a few thousand patients to be efficient is probably way off. Some estimates suggest you need a million patients. Hospital systems are responding to this scale need and scaling up. As we have seen though, a larger company is not the most efficient when it comes to innovation or lowering cost without significant forms of competition.

And that’s where the ACO model is probably not like the HMO model. The ACO model is encouraging super-regional entities to be formed that will reduce competition in a given service area versus increase it. Unlike national Payers that look a bit more like Walmart, super-regional ACOs will be large, but not super large. They willl not have competition in the area. And improving their productivity is a bit suspect (I hope they do improve their productivity by the way). And hospital systems are fighting changes to allow clinics to become more prevalent as well as allowing non-physicians to write prescriptions because that draws power away from them.

It has been widely studied and reported that HMOs reduced choice as a trade-off to obtain the benefit of reduced costs. This reduced choice is not directly present in the ACO model although both Payers and Providers want patients to stay in network of course and have been forming “lean” or “focused” networks just for this reason. So there are no large forces in the Act to strongly motivate that ACOs will help manage and control consumer choice.

So on the surface, ACOs look like a good model but they become questionable fairly quickly. You can place your bets on what will happen or wait it out. It is clear that will take years to demonstrate  if ACOs are working just like it did for HMOs–way after they were killed off.

There are actually ways to fix many of these issues by addressing the underlying problems directly. For example, creating more uniform outcomes by standardizing processes and the quality of practicing physicians may reduce the need to have the ultimate “go anywhere” flexibility driven by a patient’s need to find quality care. We need to promote competition on a very broad scale across multiple geographies by changing laws. Reduce Provider power around Rx writing and get people into clinics and alternative care delivery centers. We can also modify the reimbursement policies and centralize risk & reward so that investors (a term I used broadly here)  receive a reward for taking risk and succeeding unlike today where they are penalized with lower payments–essentially creating a disincentive to invest.

All of these ideas would have create a dramatic change in the cost curve over time without fundamentally altering the landscape. It would be a good start.

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