Accountable Care and Academic Medicine: oil and water?

At first look an academic medical center might be the perfect setting for an accountable care organization. They have the physician specialties needed to manage the most complex of medical problems, they have a hospital, and they have training programs for many of the ancillary disciplines that can contribute to efficient care in the most appropriate settings. So does this mean that we have found the answer to the ACO development question? Hardly.


At present academic centers are certainly not examples of efficient care. Patients frequently have issues getting appointments with the subspecialty physicians they need to see, some physicians try and limit the number of uncomplicated cases, and lengths of stay often are longer as residents, fellows and attendings all try and participate in care.

Academic centers are often rich in clinical data systems but frequently few “talk” to each other. Research systems typically don’t mesh with the electronic health record and often the hospital data system has limited connectivity to the ambulatory one. Tracking the cost of care is frequently beyond the realm of possibility.

Does this mean that academic centers should give up and wait to see who might want to contract for selected services? Not if they want to remain viable. Patient care revenue now accounts for more than 70% of total funding for many centers and this is likely to increase as public and private funding sources are strained for cash. Academic centers need to address issues such as patient access, physician collaboration, and cost containment with or without ACOs. Any time spent now will simply better position the center for whatever opportunities develop in the near future.

One problem that may hinder academic centers from sponsoring an ACO is a limited community primary care base. Most have existing relationships with regional specialists but only limited contact with family physicians and general internists. This might be a great place to start. Building a network of affiliated physicians will not only strengthen the primary care teaching program but will allow the academic center to gather the magic 5,000 members should they decide to proceed with an ACO.

So what should be the first steps? Clearly a visioning session that includes leadership of the hospital and academic faculty to decide if they have the commitment to transform their care model is step one. If that goes well then they need to reach out to the community physicians. Once the academic center realizes that it needs community resources as much as the community needs them there will be a basis for further collaboration.

Maybe ACOs will just go away?

Although regulations related to the reform legislation, in proposed form, are expected to be released in the coming weeks it is unlikely that they will reach final format for months. It is also likely that the volume of comments generated by the proposed regulations will be substantial. Add to this the changing atmosphere in congress and we can be sure that we have no idea what the end product will look like.


Can we take a collective sigh of relief and turn our attention to other pressing matters? Hardly. The most controversial aspects of the reform law are mandated benefits, the impact of the rules on small business, and insurance premium controls. How we deliver care (called ACOs) isn’t really part of the debate. Whatever we decide to call this collaborative care model we shouldn’t expect it to go away since the future of Medicare Part B depends on it. Likewise employers will want to see some action on the reduction of their health benefit costs and employees are tired of the cost shifting of health insurance by their employers. All this means that we need to continue our focus on ways to deliver care in an efficient, high quality, cost conscious fashion.

Granted we don’t yet know what the government expects from the ACO or exactly how money will change hands but don’t for a minute think that hospitals, physicians, and others working in a collaborative environment with rich clinical and cost data availability won’t be in all our futures.

Don’t be the deer in the headlights. There is plenty of preliminary work that needs to be done regardless of what an ACO will look like or even what it will be called. Get started.