Thursday, May 07, 2015

Is this what you call success?

“I am not sure how to explain it. It's hard to tell exactly what's going on, but whatever it is, it looks like it's good."

Well, that's sure a ringing endorsement of the Pioneer ACO experiment.  Medicare is so intent on proving that this ACO model is a success that they have to use words like this (reported by Melanie Evans in Modern Healthcare) to describe the results.

Previously, though, they acknowledged that the model does not work.  Let's go back to December, when Jordan Rau at KHN reported:

Health care systems experimenting with a new way of being paid by Medicare would have three extra years before they could be punished for poor performance, the federal government proposed Monday.

As I noted at the time:

The rule comes because many organizations have withdrawn from the ACO scheme or threaten to do so.  They have concluded that the risks just aren't worth the potential gain.  So now, CMS tries to solve that problem by essentially removing the risks.

This kind of reversal represents a kind of muddied thinking that is an indication of ideological public policy formulation. 

Melanie's report is rife with CMS's reported contradictions, starting with the lede:

Medicare says the pilot did well enough to expand. But it's unclear how the participants got the savings and to what extent others can replicate the success. 

Let's look at the criteria for program expansion under the Affordable Care Act:

The program did not add to Medicare's budget and the quality of care did not suffer.

That's sure a low legislative hurdle.  But what actually happened?  Read these sentences together and try to make sense of them.  They raise huge questions about the structure of the program and the methodology used to evaluate it.

As a group, the ACOs reduced spending on hospitalizations, which is one of the primary aims of the model. 

One perplexing result from the CMS analysis was a drop in spending for primary care office visits.

McWilliams' analysis found an increase in outpatient spending but a shift away from care in hospital-based outpatient centers.

An independent review of Pioneers' first two years offered few insights into why primary care spending declined or what may have contributed to success among those that saved money. 

Researchers with L&M Policy Research who analyzed the organizations' results said it was hard to identify strategies that helped to save money. 

I really wish CMS would focus instead on its own practices that encourage billions of dollars in wasteful hospital investment in high-cost technologies.  That's where to find the savings, not in these poorly constructed and evaluated programs.

1 comment:

Anonymous said...

I agree that CMS is desperate to say the ACOs are a success and saving Medicare money. Since this is essentially a capitated risk program, it comes down to how much money CMS provides the ACOs in their annual risk budgets (it's a lot easier to take on risk with inflated budgets!). Seeing as Medicare Advantage programs take the "healthier" Medicare members out of the Medicare population you would assume the remainder (the ACO populations) are sicker and more expensive so it all comes down to the budget to care for these people. Also, would these "savings" go back to CMS, the ACOs or some type of split? Not really savings to Medicare if the ACOs come in under budget and keep the surplus money. This program is poorly designed.... auto assigned Medicare members to ACOs without their knowing and the patients can go to any Medicare provider or hospital. Hard to be at risk for a population that doesn't know they are in the product and can go anywhere they want. That is why I think the annual risk budget would be the key to making this program a "success" they can say is working.