By David J. Nyweide, Woolton Lee, and Carrie H. Colla
Health Affairs, June 2020
Both the number and the size of accountable care organizations (ACOs) in the Medicare Shared Savings Program have been increasing. The number of ACOs rose from 220 in 2013 to 548 in 2018, while the average number of participating clinicians in ACOs increased from 263 to 653. Although increases occurred for primary care physicians (from an average of 141 to 251) and medical specialists (from an average of 76 to 157), the increase for nonphysician practitioners (from an average of 47 to 245) was the largest. These differential increases changed the ACO workforce composition over time. The average proportion of nonphysician practitioners in ACOs grew from 18.1 percent to 38.7 percent, with a commensurate decline in the average share of primary care physicians from 60.0 percent to 42.2 percent. As value-based care models grow in prevalence, their evolving clinician composition may affect workforce patterns in the broader health care delivery system.
By Don McCanne, M.D.
Supposedly accountable care organizations (ACOs) are designed to make physicians more accountable for quality and costs of health care. This study shows that in ACOs the proportion of primary care physicians are declining by 30% (from 60.0% to 42.2%) whereas the proportion of nonphysician practitioners are increasing by 114% (from 18.1% to 38.7%).
So far the studies of ACOs have been quite unimpressive as far as cost savings are concerned. With this large of a shift of services from higher paid physicians to less costly nonphysicians, it seems that more significant cost reductions should be in order. Can it be that the inefficiencies of the extra administrative costs of ACOs is consuming the potential cost savings? Are patients getting a better deal by switching to nonphysicians even though there is not much saved by that shift? And quality? Are patients receiving higher quality care by switching to nonphysicians?
There are plenty of reasons to believe that the ACO experiment has been a failure. The added efficiencies that should be attainable by shifting some care to nonphysicians should be beneficial from a cost perspective without impairing quality. But apparently the ACO model has been a failure on this count as well.
Let’s dump the failed ACO concept and move forward with the more efficient single payer model of Medicare for All wherein all health care professionals are serving in positions for which they are appropriately trained. That can help us actually achieve higher quality at a more affordable cost.
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