The Patient-Centered Medical Home and the Accountable Care Organization
The Urban Institute defines an Accountable Care Organization as a local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined patient population. The overall goal of the ACO is to reduce costs through enhanced preventative care and disease management, improve quality through coordination of care, and develop the necessary skills and resources to meet the cost and quality health care goals in the present and future. ACOs that achieve quality and cost targets will receive a financial bonus. Care for patients is provided across the continuum of care, in different institutional settings.
The joint principles of the Patient-Centered Medical Home describe the PCMH as an approach to providing comprehensive primary care as a health setting that facilitates a continuous relationship between patients, the patient's family when appropriate, and the patient's personal primary care physician.
The concepts of Accountable Care Organizations and the Patient-Centered Medical Home are in lockstep with each other. The Patient-Centered Medical Home is patient-centered care based around a core set of principles to improve quality and safety, financial and clinical outcomes, physician and staff satisfaction, and patient engagement, while also lowering the total cost of care. PCMH is about improving outcomes -- producing results not volume. Accountable Care is also about outcomes and improving quality while lowering costs. Accountable Care by its very name implies accountability and responsibility for both costs and care delivered.
The interest in the Accountable Care concept lies in the concept of shared savings along with defined shared responsibility. Many feel that for costs to truly be controlled, (while maintaining quality and access to care) the individuals and institutions that ultimately impact those costs---physicians as well as those that provide the services that physicians order, such as hospitals -- need to share in the overall savings. That is where the "shared savings" concept of Accountable Care comes from.
The challenge is that there is obviously a limit to how much savings can be squeezed out of the system and then there needs to be a steady state of a rational compensation model for all stakeholders in the health care system.
There is growing tension around who should ultimately be recognized as an Accountable Care Organization and the critical need for clearly defined criteria around the ACO model. Should it be physician-focused, as in the PCMH concepts or hospital-focused, as the source of much of the cost in the current health care system? There is valid concern in the physician world that if the Accountable Care Organizations are hospital systems, then the value of primary care and the principles of PCMH might be lost or at least severely diluted.
A long-term ray of hope for primary care is that the types of payments associated with the ACO model should allow ACOs to increase primary care compensation through quality and cost incentives, which in turn will continue to drive more young physicians into the specialty.
Accountable Care absolutely must be about improving and maintaining the health of a population of patients and not just controlling costs. It must be about proactive and preventative care and not reactive care. It must be about outcomes and not volume or processes. It must be about leveraging the value of primary care and the elements of the Patient-Centered Medical Home.
Physicians often ask what Accountable Care has to do with them. Physicians must be at the forefront to insure that Accountable Care Organizations are built on a foundation of coordinated and comprehensive, patient-centered care by primary care physicians. As AAFP President Roland Goertz, MD said recently in an ANN article about ACOs, "At this point, the law allows a broad definition of an ACO, and that allows physicians to play a significant role in how ACOs can be organized." Primary care practices should be embracing the concepts and elements of PCMH and transforming their practices in a judicious but expeditious manner. Practices that have not transformed or are not viewed as thought leaders may be left out of whatever develops in the "yet to be determined" world of Accountable Care Organizations.