ACO model boosts quality metrics, but savings harder to achieve

Institutions participating in the Centers of Medicare and Medicaid Services (CMS) Physician Group Demonstration Project (PGDP) have not demonstrated a substantial reduction in imaging that could be directly attributed to the Affordable Care Organization (ACO), according to an article published online Dec. 13 in the Journal of the American College of Radiology. However, the article also contends that incentive-based methodology seems to successfully increase compliance for measuring quality metrics.

One of the numerous complex and challenging problems facing the U.S. government is that of the uncontrolled increase in health care expenditures. According to the article’s author, Suresh K. Mukherji, MD, MBA, of Michigan State University in East Lansing, some estimates predict that one-fifth of gross domestic product will be health care expenditures in 2021.

“The unabated rise in health care spending is a growing burden on families and businesses and a threat to the fiscal stability of the government,” wrote Mukherji. “Health costs are now the third highest government expenditures following defense spending and social security. The high level of spending allocated to health care reduces our ability to invest in other parts of our economy and adds to our unsustainable national debt.”

The initial ACO design was based on results of the CMS PGDP, in which ten physician group practices participated. CMS initiated a shared savings model with medical groups, allowing them to receive payments of up to 80 percent of generated savings. The groups were required to comply with 32 quality measures that were phased in during the five year project period.

The results of the PDPG, which ended in 2010, reveal that all participants did well on the quality metrics during the five years. By the final year, seven participants achieved benchmark-level performance on all 32 measures and the others achieved similar results for at least 30 of the measures. The financial results, however, were drastically different. Only two of the PGDP participants surpassed the two percent savings threshold for the first year of the project, and half of the participating organizations exceeded the threshold after three years.

According to Mukherji, the ACOs will not have a direct effect on imaging for several reasons. These include the fact that ACO quality metrics that measure imaging utilization designed to specifically reduce imaging use don’t exist, as well as several realities related to radiology’s value chain.

“Therefore, it is absolutely essential that radiologists work at all levels of our health system to ensure that the proper study is performed and to eliminate those studies that are not indicated in collaborative and cooperative manner,” wrote Mukherji. “The overall goal is to ensure that the right study is ordered for each individual patient, which will dramatically reduce inappropriate utilization of imaging while increasing quality.”

Eliminating the ability to self-refer, supporting tort reform measures to reduce the practice of defensive medicine, and funding comparative effectiveness research initiatives that support the development of practice guidelines and appropriateness criteria are several ways to reduce overutilization and lower costs, advises Mukherji.