Since it began three years ago, Medicare's test of accountable care
hasn't asked beneficiaries who are not assigned to an accountable
care organization whether they want to voluntarily enroll. That will change
next year when some Pioneer ACOs will give beneficiaries that option.
The CMS Innovation Center is testing whether seniors will elect to enroll
in an ACO, a term that means little or nothing to many patients despite
an aggressive push to promote accountable care among hospitals and doctors.
The Pioneer ACO demonstration also will evaluate whether patients who
agree to enroll are more likely to stay within the ACO's provider
network and seek care from ACOs' hospitals and doctors.
Patients' track record in staying within the ACO network has been spotty
among Medicare ACOs. Unlike Medicare Advantage managed-care plans, which
are allowed to use deductibles and other strong financial incentives to
steer patients toward network providers, patients in Medicare ACOs can
seek treatment anywhere with no financial penalty. And indeed, they often
wander outside the network. That undermines ACO efforts to manage quality
and costs and weakens incentives for ACOs to make investments in services
or programs that won't deliver immediate returns, experts say.
“We have to be creative right now, in the absence of tools that we
have in managed care,” to encourage patients to seek care within
the ACO network, said Colin LeClair, executive director of Monarch HealthCare,
an ACO that is inviting patients to enroll.
Until this year, patients were enrolled in—“attributed to”
in ACO jargon—a Medicare ACO because their doctor was participating.
The CMS Innovation Center has included patients within an ACO based on
how much care they got historically from ACO doctors. Patients are informed
by letter. Currently, patients can opt out of allowing the ACO to share
their medical data but they still are included in the ACO's cost and
quality baselines and in the ACO's final performance results.
But one-third of patients in ACOs turn over each year because they seek
too much care outside an ACO. Nonetheless, Pioneer ACOs are rewarded or
penalized based on the cost and quality of healthcare services for patients
who are identified and attributed at the start of each year.
That enrollment strategy will continue to be the case next year. But in
2015, additional patients will be able to choose to be enrolled. The Innovation
Center said five Pioneer ACOs will solicit patients to enroll. Invitations
will go to Medicare patients not included in an ACO in 2015, based on
their primary-care doctor this year, but who were previously included.
Signing up for an ACO may make patients more conscious of the quality-of-care
benefits of ACO enrollment, and may nudge them to stick with the ACO's
network doctors and hospitals, LeClair said. Patients who elect to join
also may be more receptive to attempts to manage their care or their chronic
disease condition once they are familiar with accountable care, ACO leaders say.
Often seniors feel vulnerable and distrustful about being solicited. But
“when we call a high-risk patient or a patient who was just discharged
from the hospital, we're not a foreign entity, we're a trusted
partner,” LeClair said. “We're here to support them.”
Irvine, Calif.-based Monarch HealthCare mailed invitations to nearly 10,000
Medicare patients, and 2,100 responded, LeClair said. Of those, about
100 declined. Monarch used letters drafted by the Innovation Center, which
worked with a behavioral economist to draft four letters to see which
version gained the highest response from Medicare patients.
But it's uncertain whether seniors will be willing to change doctors
or habits that take them outside an ACO simply because they signed up
for an ACO. Beneficiaries in the traditional Medicare program who join
an ACO can continue to seek care anywhere and from whomever they would
like. “It's not clear that would necessarily change the care
patterns,” said Dr. J. Michael McWilliams, an associate professor
of health policy at Harvard University who has studied managed care and
The invitation to voluntarily join an ACO may confuse seniors, say some
ACO executives who decided not to participate in the test of voluntary
enrollment. They may mistake the ACO for a Medicare Advantage plan, which
restricts their choice of provider.
In Minneapolis, Park Nicollet Pioneer ACO officials feared that this type
of invitation would confuse seniors and require significant time and effort
from staff to explain the offer. And they thought it ultimately would
do little to change patients' provider choices, said Donna Zimmerman,
senior vice president, government and community relations for HealthPartners,
which includes Park Nicollet.
Her ACO will wait to see whether invitations by Monarch are effective in
getting patients to stay within the ACO network. “It's absolutely
a fair question and a tactic that can be tried out,” she said.
In Peoria, Ill., where managed care is not as common as in other geographic
areas, older Medicare patients have little experience with limited networks
and may find the ACO invitation perplexing, said Dr. Ralph Velazquez,
senior vice president of care management for OSF HealthCare, which operates
a Pioneer ACO. Older seniors may have little appetite for accountable
care, he added. OSF is debating whether to invite seniors to participate.
Experts say marketing ACOs to patients could cause risk-selection issues.
Recruiting patients creates opportunity for ACOs to pursue those with
spending likely to be less than projected and avoid those whose care is
likely to exceed projected targets. ACOs earn bonuses when health spending
is less than projected, based on patients' historical use.
That potential problem can be minimized, however, to the degree that spending
targets account for predictable fluctuations in spending and include adequate
risk adjustment for sicker patients, said Michael Chernew, a health policy
professor at Harvard University. The better those spending targets adjust
for risk, the less worry “about untoward things happening,” he said.
For the coming year, the Innovation Center will use a more sophisticated
risk-adjustment formula to adjust spending projections for more complicated,
expensive patients, ACO executives said.
Even so, research suggests seniors with cognitive impairment or limitation
may be less likely to enroll in an ACO despite potential improvements
in their care, McWilliams said. Such patients were less likely to sign
up for low-income subsidies for Medicare Part D prescription drug coverage,
according to a study McWilliams and others published in 2013 in JAMA Internal Medicine.