May 24, 2018
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Early success on Obamacare model, but too soon for judgment

Kevin Bennett | BDN
Kevin Bennett | BDN
Cynthia Herrick, registered nurse at Husson Internal Medicine, calls a patient on the phone to check to be sure they are taking their medicine and to answer any questions regarding their healthcare. Herrick is part of the Eastern Maine Healthcare System accountable care organization which is part of a national experiment to transform how health care is provided and paid for.


The Affordable Care Act has received so much attention for its potential effects on health insurance, it’s easy to forget the far-reaching law is also about changing how providers deliver health care and patients consume it.

The federal government last month released the first round of data on one of the Affordable Care Act’s most ambitious efforts to change health care itself. The law’s champions and critics could each find something in the data release to bolster their position. But no one should be drawing sweeping conclusions about a new health care model’s viability with such a limited pool of data after just one year of an ambitious pilot program.

The data came from 32 health organizations from across the country that were accepted into the Pioneer Accountable Care Organization Model pilot project, which involves patients enrolled in Medicare, the government-funded insurance program for seniors.

The project is one of a number of initiatives happening in the health care world to try out the accountable care model, in which health care providers are held financially accountable for their patients’ health. They’re rewarded when patients stay healthy and require less care, and they’re penalized when the cost of patients’ care rises.

The current trial initiatives underway help their participants take baby steps away from health care’s current fee-for-service model, in which providers are paid for each procedure they perform and each test they order.

What sets the Pioneer ACO project apart from many other pilot initiatives is that its timeline is aggressive. In its second year — 2013 — participants can share in any savings they produce, but they’re also at risk for losing money if they can’t rein in health care costs.

The first-year results showed overall — though not universal — success for the Pioneer ACO program. Health care costs for the 669,000 patients involved grew by 0.3 percent in 2012, compared with 0.8 percent for comparable Medicare beneficiaries not involved in the program. Thirteen of the 32 organizations produced $87.6 million in savings, returning $33 million of that sum to Medicare. Two participants saw their health care costs rise, forcing Medicare to chip in an additional $4 million.

According to the federal Centers for Medicare and Medicaid Services, the savings came largely from a drop in hospital admissions and readmissions among participating patients.

Nine of the 32 Pioneer ACO participants — more than a quarter — dropped out of the program after the first year, before they would have been at risk for losing money. But the fact that the program lost nine participants doesn’t mean accountable care isn’t a viable model for improving patient care and providing it at a lower cost.

Seven of the nine organizations that left shifted instead to another accountable care program called the Medicare Shared Savings Program, under which participants can share in savings they produce but aren’t at risk for losing money if they don’t lower costs.

Brewer-based Eastern Maine Health Systems is one of the Pioneer program participants, involving a number of the primary care practices and hospitals within its network. And it’s one of the Pioneer participants that lowered health care costs and returned savings to Medicare.

It was selected for the aggressive program because of its experience in coordinated patient care, a care model in which doctors and nurses work with patients to manage chronic diseases in a way that doesn’t require frequent visits to the doctor or to the hospital emergency room.

“We’re trying to do a lot of management at home because that’s the right environment for all of us,” said Dr. Iyad Sabbagh, a physician at Husson Internal Medicine in Bangor and the medical director for Eastern Maine’s accountable care organization. “Why does the care have to wait until you get to the doctor’s office?”

That means doctors and nurses work with patients to construct plans for managing their conditions — like diabetes — at home. The plan might involve a new diet and habits like regular blood sugar tests. Nurse care coordinators follow up with patients by phone or email to make sure they’re on track.

It’s a shift in culture. Under an accountable care model, a patient success story isn’t necessarily a productive visit to the doctor’s office. Success is when the patient stays away from the doctor’s office altogether.

“We had to reexamine, what is access to care?” Sabbagh said. “It’s not physical access as much as disease management. It could be by phone. It could be by email. It could be someone coming into your home.”

The federal government released only limited data from the Pioneer ACO program’s first year. We only know a few of the metrics, for example, by which participating organizations are being measured. We don’t have the raw data on costs and savings.

It would help patients, insurers and other health care providers to know more about a model of health care that’s being heralded as the way of the future and as a model that can cut costs and improve patient care.

Given what little information is available and the fact that a pilot program offers a chance to experiment and learn, it’s too early to draw sweeping conclusions and prematurely label an Obamacare program an unheralded success or a categorical failure. There is reason, however, to be encouraged.

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