De-fragging health care
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Few would disagree that the fragmented American system of delivering and paying for health care is dysfunctional. Physicians and hospitals get paid by the office visit, hospital admission or diagnostic test, and nobody is held economically responsible for the outcome of patient care from start to finish.
Largely overlooked in the ongoing health reform debate is whether the diverse players in the health industry can be encouraged to cooperate, coordinate services, control costs and, most importantly, ensure high quality of care.
By next year, a little-noticed provision of the Affordable Care Act of 2010 ("Obamacare" to its critics) may begin to bring accountability to a system with few checks and balances -- if enough health care providers are willing and able to participate.
The health reform law includes a new Medicare Shared Savings program set to take effect in 2012 for qualifying "Accountable Care Organizations." The program is designed to create financial incentives that reward ACOs for reducing spending while maintaining quality.
These new networks will need to develop the infrastructure to track costs and quality indicators, and they haven't been given much time to organize. The jury is still out on whether this program will prove feasible, affordable and sufficiently financially attractive to doctors and hospitals to make a dent in Medicare costs. The good news is that Pennsylvania may be in front of the curve for a change.
Under the Affordable Care Act, an ACO network must include primary care physicians and can include specialists, hospitals and others. An ACO would coordinate all care needed by a pool of at least 5,000 designated Medicare patients and would share the cost savings they achieve over certain benchmarks. Large integrated systems like UPMC or West Penn Allegheny Health System can apply, but networks of smaller, unaffiliated physician groups and independent hospitals may also qualify. Highmark's planned acquisition of WPAHS likely will include efforts to develop an ACO.
First Published July 13, 2011 12:00 am
