My mother, who is 77, has always been one of the healthiest people I know. For years, she played tennis and golfed regularly, took long walks with her dogs (most recently Shorty, the Welsh Corgi, and Topper, the Cairn Terrier), and went on more trips than I can count to Mexico, Europe, and around the US.
But, last fall, something went wrong. Her wrists started swelling and aching. And then it moved into her neck. She needed to find a doctor to sort out what was going on and help her address the problem and quickly. Like many other Medicare beneficiaries in the traditional fee-for-service program, she referred herself to a specialist who she found by asking a friend.
As I watched the episode unfold, I wondered: How would this have been different if my mother were in an accountable care organization (ACO)?
Deloitte sought to answer a similar question in its recent piece, Integrating specialty care into accountable care organizations: Perspectives from the field, which was published in Health Affairs this week. Through interviews with leaders at eight ACOs, we found two major trends among ACOs attempting to integrate specialists into their care models.
Influencing referral patterns: Many organizations are directing their efforts at primary care physicians aligned to their health system. A key goal for these ACOs is helping primary care physicians understand the practice patterns – patterns of quality and cost – of specialists in their area. By sharing the data on these patterns, they aim to help primary care physicians refer patients to specialists who consistently have strong results and low costs. This does not happen without challenges. Getting enough data to assess the comparative performance of specialist physicians in the market and having the right quality measures for all the types of specialists have both been major challenges for these systems.
Improving specialty care: Few organizations are trying to influence how specialists practice medicine. One organization said it had begun trying to influence the cost and quality of care it provided with a broad set of physicians only to realize that first it needed to start with primary care physicians. Another organization said it had tried working with specialists on a few focused projects (e.g., working with a group of orthopedic surgeons to improve care and reduce costs for people with low-back pain). The local business community made the project easier because it had strong interest in this condition. Ultimately, the health system successfully made the case to the specialists that their attention to this condition could generate additional referrals from these employers.
Should ACOs be doing more to influence cost and quality in specialty care? Many experts say yes. They recognize that because specialists are so influential in driving health care spending, ACOs will need to influence the way they provide care. Today, research suggests that progress on this front is slow; in the future, data on costs and quality and new payment methods are likely to be as important for specialists as they have become for primary care physicians.
Influencing specialists is likely to be challenging, however, as many specialists have successful practices under traditional payment methodologies. Specialists make almost twice as much as primary care doctors, and some types of specialists continue to be in high demand. Picking and choosing isn’t always an option.
Deloitte’s 2014 Survey of US Physicians echoed this, finding that specialists were significantly less likely to have any of their compensation tied to value-based care arrangements.
Despite these obstacles, involving specialists is critical to the goal of improving the value of ACOs. A strategy aimed solely at primary care doctors may do little to improve the care patterns of Medicare patients like my mother who find their own specialists.
When I asked my mother why she hadn’t gone to her primary care physician to help her find a specialist, she said she only went to her internist for check-ups. Instead, she began by calling specialists and was confronted with receptionists who conveyed months-long waiting lists. Her search ended with a family friend (a retired internist) who helped her get in the door with a rheumatologist. To me, this was a missed opportunity for her primary care physician to engage with my mother, coordinate her care with the specialist, and help her get the care she needed to address her pain.
My mother, it turns out, has rheumatoid arthritis. Fortunately, she is responding well to medications, and she likes the physician she is seeing. Unfortunately, today it’s hard to tell whether she’s seeing a specialist who thinks in terms of quality outcomes and a conservative practice style or one who continues to fly solo.