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What’s A Surgeon’s Role In An ACO? Not Much So Far, Survey Says

By Jenny Gold

June 5th, 2014, 1:11 PM

Accountable Care Organizations have given little attention to surgery in the early years of the Medicare program, choosing to focus instead on managing chronic conditions and reducing hospital readmissions.

That’s according to a case study and survey published this week in the journal Health Affairs. The authors conducted case studies at four ACOs in 2012 and sent a survey to all 59 Medicare ACOs in the first year of the program, with 30 responding.

“I’m a surgeon, so I was really curious as this model probably continues to gain steam, what’s this going to mean for me?” said lead author James M. Dupree, a urologist at Baylor College of Medicine. “We found that thus far, very little of the strategic attention seemed to be devoted to surgical care and the integration of surgeons into the ACO.”

That may be a missed opportunity. Surgery represents 50 percent of hospital expenditures, and “thus, even if ACOs are able to achieve their goals in chronic disease management, overlooking the role and cost of surgical care may negate those savings,” the authors write.

They found that surgery was not part of the strategic plan for the first year at any of case study ACOs, and 86 percent of survey respondents rated the priority of reducing unnecessary surgery as “medium,” “low” or “very low.”

This is not surprising given that none of the ACO quality metrics focus on surgery.  But ACOs will likely shift their focus to surgery as the program matures, experts said.

“Any thoughtful leader has a laundry list of things a mile long that they’d like to work on, and working with the surgeons and the specialists just isn’t at the top of the list. It’s something they’d like to do later on,” said David Muhlestein of the consulting firm Leavitt Partners.

It’s not just surgeons, he adds. “Dermatologists, endocrinologists, all the different specialties want to know how they fit in, but generally ACOs are not prioritizing the specialties. They’re focusing on the lowest hanging fruit, and generally the specialties aren’t the lowest hanging fruit.” It’s easier to focus first on things like reducing expensive hospital admissions by managing the care of patients with chronic illnesses, including diabetes.

Another reason, he says, is that it’s hard for an ACO to figure out how to share savings with specialists like surgeons. With a primary care physician, it’s relatively easy to figure out their share of the ACO’s savings by factoring in the number of patients they see. “It’s harder with specialists who may only see a handful of patients a week,” he said

Reducing unnecessary surgeries might be better achieved by helping primary care physicians change their referral patterns rather than targeting the surgeons themselves, said Muhlestein, who had no role in the survey or case study. Many patients may not need to be referred to a surgeon at all when there’s a medical treatment. And for those that do, he says, “you want to refer to a surgeon who is thoughtful and conservative about the decision to operate.”

The authors of the Health Affairs article also found that the amount of any possible shared savings for surgeons would be smaller than the potential revenues they could generate from additional surgeries. Therefore, changing referral patterns to those surgeons might actually be a more effective way to manage the cost and quality of the care they provide.

“A surgeon who was left out of an ACO, or asked to leave an ACO because of poor performance, would risk losing a referral stream from primary care physicians who participated in the organization,” they wrote.

And ACOs may simply not be the best model for managing surgical quality and cost, said Rob Lazerow of The Advisory Board Company: “The ACO model is only one part of the payment transformation going on right now, and it’s probably more effective at rewarding providers for reducing avoidable care than for making unavoidable care more efficient.”

In other words, ACOs are good at reducing the number of surgeries, but not at making the surgeries that have to happen more efficient.  He says the bundled payment model, in which providers get a set amount of money to handle an episode of care, “is a much more direct way to reward surgeons” who are practicing efficiently.

4 Responses to “What’s A Surgeon’s Role In An ACO? Not Much So Far, Survey Says”

  1. Jackson says:

    Contrary to what surgeons believe, not every illness and not every injury requires surgery as a treatment of first choice. Surgeons are trained to perform surgery. It is not surprising that surgeons almost always choose surgery at the top of their list of treatments. That is why I choose an osteopath as my primary care doctor. Osteopaths almost never view surgery as their first choice of treatment. Osteopaths believe that the body is designed to heal itself in many cases. The job of an osteopath is to carefully and methodically encourage that healing process. Granted, serious trauma such as broken bones and deep lacerations require immediate medical intervention, probably at the emergency room. However, aches and pains of a mysterious nature do not always need exploratory surgery as a method of first choice. There are many treatments to employ before surgery is considered. As I see it, an ACO needs access to surgeons but surgeons do not necessarily need to be on staff.

  2. Penelope says:

    I agree with Jackson: the purpose of the ACO model is to coordinate care across all facets of healthcare, in order to promote patients’ overall wellness (and simultaneously reduce cost). If preventative care is made a prominent component of that general wellness (which I believe is happening more and more so) surgeries for non-emergencies should ultimately become less frequent.

  3. We see ever-increasing role of surgeons and other medical specialists within a coordinated environment like ACO/IPAs and medical homes organizations. It is all about interoperability; which unfortunately cannot be achieved within ambulatory ACO, even if a hospital joins the ACO. Simple fact: ACOs are comprised of independent PCPs and specialists and as such they will always be running disparate EMRs with no hope to achieve meaningful connectivity for years to come. The key to success for an ACO or any healthcare organization that strives to provide better care is interoperability and analytics of existing data which can only be achieved by the EMR-agnostic solutions. There are few disruptive solutions that focus on the aspect of connectivity between physicians and already being used nationwide: ZocDoc, healthGorilla, TigerText. ACOs can succeed by adapting to the change, not trying to create a uniform platforms out of dozens of EMR systems in their communities.

  4. Alan says:

    As a vascular surgeon I am constantly amazed that comments like those made by Jackson and Penelope are not immediately dismissed as the biased drivel that they are. Surgeons do NOT believe every illness can be cured or improved by an operation. The vast majority of surgeons that I know carefully evaluate the risks and benefits of any recommended treatment, including not operating, before treatment is initiated. Taking someone to the operating room is a huge responsibility – one that is not ever taken lightly. I find that my non-surgical colleagues are quicker to recommend or perform interventions (endo-vascular ) rather than try medication or life-style modification – than we are. Probably because if it all goes wrong they will just call me to come fix it. Thoughout surgical training and beyond, the surgeons constantly reassess the downside of their operations and to suggest the we only think with our scalpels is not only demeaning but also ignorant. An ACO that ignores its surgeons and their positive contributions to the overall patients health is doomed to failure.