Accountable Care Organizations (ACOs) are groups of healthcare providers, who come together voluntarily to deliver coordinated care to a defined patient population.
The Affordable Care Act in 2010 and the Medicare Access and CHIP Reauthorization Act of 2015 promote ACOs for Medicare patients and encourage a merit based payment system by the end of 2018. Previous attempts to control costs with Health Maintenance Organizations (HMOs) were perceived as rationing care. Later, Physician Hospital Organizations (PHOs) were perceived as restricting care. Instead of forcing a cost control mechanism on physicians and patients, ACOs are focused on outcomes: a healthier patient population and lower costs. Electronic health record data and claims data are essential for an ACO to understand and prove performance.
Medical Clinic of North Texas (MCNT), an affiliate of USMD Holdings, Inc., (NASDAQ: USMD), was selected as an accountable care organization in 2013. USMD is an innovative, early-stage physician-led integrated health system of 250 physicians located in the Dallas-Ft. Worth Metroplex. The majority of physicians are primary care providers. In 2014, an internal gastroenterology program was developed based upon evidenced based quality metrics and customer service processes.
The #1 priority for USMD Gastroenterology is improving colon cancer screening and post polypectomy surveillance. Key metrics include percentage of patients screened, adenoma detection rate and timing of follow up surveillance colonoscopy. The United States Preventative Services Task Force (USPSTF) suggests appropriate colon cancer screening options.1Colonoscopy is suggested throughout USMD as the preferred colon cancer screening modality. However, non-invasive stool fecal immunochemical testing (FIT)is offered to patients who refuse colonoscopy. Another non-invasive stool DNA test, Cologuard® is now available for patients that refuse colonoscopy. Monitoring screening rates and increasing the goal rate will document our performance. Currently, 80% of our patient population is compliant with a USPSTF screening option. We have therefore increased our goal rate to 83%.
The American Society for Gastrointestinal Endoscopy(ASGE) has published goal adenoma detection rate of 30% for men and 20% for women undergoing a screening colonoscopy.2A higher adenoma detection rate is associated with decreased risk of colon cancer.3The USMD gastroenterology adenoma detection rate is 48% for men and 43% for women. The appropriate timing of follow up colonoscopy is a major focus to reduce unnecessary testing. In 2012, ASGE released consensus guidelines regarding timing of a surveillance colonoscopy.4The most common scenarios are listed below:
Baseline colonoscopy findings: Recommended surveillance interval (y)
No polyps 10
1–2 (<10 mm) tubular adenoma 5–10
3-10 (<10 mm) tubular adenomas or 3
tubular adenoma >10 mm or villous adenoma
Using these evidence based guidelines can standardize the timing of a follow up colonoscopy. Getting patients the care they need (not too little, not too much) can improve health and minimize costs. With increased health and lower cost, healthcare value for a patient population can be achieved.
To increase access and reduce cost of a colonoscopy, we have a direct access scheduling system, offer Saturday colonoscopy days and use lower cost preps. With our direct access program, healthy patients can schedule a colonoscopy over the phone with our clinic staff and skip a pre-procedure office visit. In addition, Saturday screening colonoscopy days for patients who do not want to miss a day of work can increase screening compliance. Finally, the colonoscopy prep is a common medication we prescribe; we use tier 1 (generic) or tier 2(low cost branded) colon preps to minimize pharmacy cost.
Traditionally, gastroenterologists have been rewarded for providing high volume endoscopy services. However, avoiding waste is mandatory in the shared savings world. The situation of USMD Holdings, Inc., (NASDAQ: USMD) being a publicly traded corporation allows for its physician employees to share the financial benefits of the ACO through traditional salary and stock equity compensation. Each ACO will have different physician compensation models, and physicians should seek to understand their ACO model.
ACOs can empower physicians to reevaluate how healthcare is delivered. With data collection and analysis, physicians can monitor and make changes to improve. The shared savings of an ACO allows physicians to reap some of the financial rewards of improving healthcare delivery.
1. United States Preventative Services Task Force, Colon Cancer Screening October, 2008.
2. Rex, Doug. Quality Indicators for Colonoscopy. Gastrointestinal Endoscopy; 2014; 81:31-53.
3. Douglas A. Corley, M.D., Ph.D., Adenoma Detection Rate and Risk of Colorectal Cancer and Death. N Engl J Med 2014; 370:1298-1306.
4. Lieberman, David. Guidelines for Colonoscopy Surveillance after Screening and Polypectomy. A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143: 844-857.