We Don’t Need No Stinkin’ Gatekeepers: Oh Really?

Some have suggested that ACOs are a new and improved as in ‘consumer friendly’ version of their managed care predecessors – HMOs.

Editor’s Note: For an excellent historical overview on the genesis of the American sick-care industry, check out ‘Health Care Coverage in the United States: A Brief History.

As an ‘HMO lite’ derivative of sorts ‘accountable care collaborations’ (including Medicare certified ACOs and a growing pool of commercially negotiated arrangements), ACOs are emerging as hybrids of traditional managed care while incorporating increasing elements of consumer or patient centric care.HMO Said I Ws Fine

Back in the day (circa 1980s & 1990s), HMOs (and there were are range of models from staff to group to network or IPAs) most were of the ‘gatekeeper’ variety – wherein primary care physicians aka ‘PCPs’ were assigned the ‘care coordination’ or care management responsibility to provide basic health services and prudently refer specialty or tertiary care services to a preferred panel of vetted (quality and cost) consultants or specialists.

While sound in theory the real world didn’t work as smoothly as network designers – if not their quant actuaries envisioned. Many PCPs provided little if any of the assumed medical necessity determinations and/or care coordination. They either routinely referred all cases, or none at all. There simply wasn’t a quality set that guarded against ‘sloppy’ or less than standard of care practice, while promoting a more prudent utilization of clinical resources. As a result, HMOs got a bad wrap which came home to roost in the movie ‘As Good As It Gets‘, when actress Helen Hunt expressed the then prevailing sentiment most felt towards these ‘mother may I’ barriers to quality healthcare.

Postscript: As a testimonial to the power of popular culture, shortly after this film United HealthGroup decided to abandon the gatekeeper HMO model and permitted direct access to specialists, thus in one fell swoop the premise (and promise) of gatekeeper medicine came to an end. 

However, one BIG difference between HMOs and ACOs is the latter must indirectly ‘traffic’ referrals ‘in network’ in order to have a shot at meeting savings benchmarks established by CMS. Whereas HMOs typically drove patients into their contracted and thus discounted network of preferred (or even exclusive) providers prospectively via gatekeepers and/or the ‘mother may I’ bureaucracy.

CMS received quite a bit of input on the disproportionate risk assumed via a ‘hands-off’ retrospective ‘attribution’ mechanism. In other words, at the end of the reconciliation period and after all member incurred costs are attributed to an ACO accounting pool, the hope was there would be savings sufficient for distribution and sharing. In a way, this represents the best in a ‘faith based’ performance model.

So at one level one might say, be careful what you pray for! Providers (not just members) also lobbied against gatekeepers and heavy handed managed care overlords, and ACOs are what we got. We shall see whether the faith placed in an accountable care ‘triple aim’ paradigm will be sufficient to drive referral patterns and prudent utilization of delivery system resources, or whether ‘the old is new again’ and gatekeeper medicine returns via a 2.0 iteration.

A recent study published by the American Medical Association in JAMA Internal Medicine titled ‘Outpatient Care Patterns and Organizational Accountability in Medicare‘ is drawing timely attention to the ‘leakage experience’ reported by many ACOs. Specifically:

 66.7% of office visits with specialists were provided outside of the assigned ACO. 

So who knows? Maybe it’s days ain’t over!

The complete results are posted below:

Of beneficiaries assigned to an ACO in 2010, 80.4% were assigned to the same ACO in 2011.

Of those assigned to an ACO in 2010 or 2011, 66.0% were consistently assigned in both years.

Unstable assignment was more common among beneficiaries with fewer conditions and office visits but also among those in several high-cost categories, including the highest decile of per-beneficiary spending.

Among ACO-assigned beneficiaries, 8.7% of office visits with primary care physicians were provided outside of the assigned ACO, and 66.7% of office visits with specialists were provided outside of the assigned ACO.

Leakage of outpatient specialty care was greater for higher-cost beneficiaries and substantial even among specialty-oriented ACOs (54.6% for lowest quartile of primary care orientation).

Of Medicare spending on outpatient care billed by ACO physicians, 37.9% was devoted to assigned beneficiaries. This proportion was higher for ACOs with greater primary care orientation (60.0% for highest quartile vs 33.6% for lowest).


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