The medical practice of Orly Avitzur, Consumer Reports’ medical director, will soon join an accountable care organization, or ACO. She will then be part of a group of doctors, hospitals and other health-care providers who have come together to offer “high-value care.”
The idea is to bring higher-quality care to patients and lowering costs by reducing the use of unnecessary tests and treatment. She is signing on because it will give her access to a larger team of physicians and other experts to help her manage patients.
You may already be one of the roughly 24 million Americans (including 8.9 million Medicare users) being served by an ACO. If not, just wait: Physician participation is increasing, so you are likely to get a letter in the near future from one or more of your providers informing you of their participation in an ACO.
The group that Avitzur is joining is a Medicare ACO, which means that all of the providers accept Medicare’s traditional insurance. (Some others accept private insurance.) The Department of Health and Human Services is encouraging more Medicare providers to consider models such as ACOs, in part to curtail runaway health-care expenses, which are leading to higher Medicare premiums for some consumers.
How? Under the traditional fee-for-service payment system, providers are compensated for each office visit, test and procedure: The greater the volume, the more they are paid. An ACO is financially rewarded for keeping patients healthy and for driving down the number of tests, procedures and doctors’ visits that have no clear benefit to the patient. A key part of that is ensuring that providers communicate more closely and help their patients — especially those with chronic illnesses such as high blood pressure or heart disease — select the right treatments and skip those that are unneeded.
If your doctor joins an ACO, your office visits may start to have more emphasis on preventive services and strategies for staying well. If you have a chronic condition such as diabetes, for instance, you and your doctor may spend more time discussing ideas for stabilizing your blood sugar.
You may also find that you have a larger health-care team. An ACO won’t reduce your time with your doctor, but he may assign a high-level nurse to help you manage your diabetes or other complex illness. Or an ACO’s pharmacist may contact you to discuss your medications.
You will also be given the choice of whether you want your health data to be shared within the ACO. That allows the doctors to study your information — along with data from many other patients — to determine how to provide the best care for all.
If you get a letter informing you that your doctor, hospital or network has joined an ACO, it’s important to do the following:
●Decide whether you want to stay with your current provider. When providers join an ACO, they are required to inform patients. You can seek a different physician if you don’t want to participate in an ACO — for example, because you’re concerned that it may restrict access to specialists or tests.
●Ask your provider to clearly explain what changes you may expect to see as a result of the switch to an ACO.
●Find out what extras, such as wellness programs or opportunities to work with nurses and other health-care professionals, may be available to you through the ACO.
●If you remain with your doctor, pay close attention to the referrals you receive. Your doctor will probably refer you only to hospitals and specialists within the ACO network. If you have other preferences, ask your provider what will be involved in seeing a doctor of your choice.
●If you believe that you need a medical test or procedure and your doctor declines, that decision may be a reflection of the ACO’s cost-saving efforts. But it’s more likely to be a reflection of better medical care. If you’re uncertain, ask your doctor why the test or procedure should not be done and which medical guidelines he or she is following.
When health-care expenditures rise, some of those increases end up in your insurance premiums. Avitzur hopes that ACOs and similar programs will encourage health-care professionals to spend more wisely.
For further guidance, go to www.ConsumerReports.org/Health, where more detailed information, including CR’s ratings of prescription drugs, treatments, hospitals and healthy-living products, is available to subscribers.