While the Affordable Care Act of 2010 (ACA) takes a big step toward expanding health insurance coverage, many Americans are concerned that the healthcare system to which they’ll gain access is broken and often fails to deliver effective and timely care.  Plus, considering the growing number of chronic disease patients and the incentives that reward providers when preventable complications occur, the cost of healthcare spending continues to rise.

Industry analysts and government officials support the development of Accountable Care Organizations (ACOs) because they feel that reorganization can help to address

the escalating problems of quality and affordability. While ACOs could feasibly take a wide variety of forms, they’re generally comprised of groups of primary care physicians, hospitals and specialists who join together in integrated networks that become accountable for the care of a certain patient population. ACOs are also eligible for financial bonuses if they meet their performance goals. The ACA’s first step into the spotlight came when the government allowed Medicare to contract with ACOs, but interest is growing among Medicaid agencies, commercial payers and a few state legislatures (including Colorado, Vermont and Washington.)

Though there has been much discussion about how to structure provider networks, reimbursement and performance-based rewards and penalties for providers, the role of patients in ACOs hasn't been discussed at length. In existing ACO pilot programs and models, patients who are assigned to ACOs are “invisibly” enrolled—in that they’re not notified and often aren’t aware that they’re even associated with ACOs.

Industry experts are concerned that since the provider-based accountability model is disconnected from the way patients traditionally sought care, it could fail to achieve the cost-saving and quality goals that have been the basis of its development all along. And, some say, it could cause friction between patients and their providers. Except in the case of closed, integrated delivery systems (like large provider organizations with capitated payment systems), most patients aren’t required to obtain care from only one provider group.

The ACO movement was aided by studies of the care patterns of Medicare patients. The studies showed that patients tend to stick to a specific provider group—73 percent of beneficiaries inpatient and outpatient services took place within a primary hospital or one of its extended multispecialty medical staff. More than 60 percent of admissions were to the primary hospital too, but 25 percent of evaluation and management visits and more than a third of hospital admissions involved providers outside regular provider groups. Since ACOs would have a certain amount of control over the care provided to their patients, they’re more likely to stick to their preferred provider groups and this could reduce cost and improve quality of their overall care.

Then again, the idea of forcing patients to stick within their ACO networks has been shunned, mostly because Americans value the right to choose their own providers. In fact, the rise of preferred provider organizations (PPOs) in the late ‘90s is partially credited to the fact that patients don’t want to be locked in to a specific group of providers. Further, most Medicare patients don’t enroll in private plans if they restrict their choices of doctors, even when these plans offer better benefits than traditional fee-for-service Medicare. This trend suggests that lawmakers ought to focus more on creating patient incentives for compliance in the ACO structure.

This is why many industry watchers say that patients should share in ACO cost savings. For example, patients could pay lower copayments for visits to doctors who are within their ACOs.  This would not only encourage patients to join ACOs, but also providers.

Since most patients consider their out-of-pocket amount when choosing a healthcare plan, patient participation in ACOs could also be increased by offering lower monthly premiums to patients who choose ACO care.  Then again, while this approach would require patients to commit to the ACO for a year or risk higher copayments by going outside of the ACO, some might see it as a way to lock them in to a specific group of providers.

Yet another possible reason patients might opt-in to ACOs is simple procrastination or failure to opt-out. Studies show that consumers often accept “default settings” because they assume that the default is the recommended set up. Private health plans might assign their patients to primary care doctors within their ACOs as a default and might charge lower copays for visits with these providers. Patients could still opt out and seek care outside of the ACO, but would be required to pay more out of pocket.

While the “opt-in or out” option is available for most private health plan, Medicare patients won’t have the same incentives without a change in legislation. Instead, CMS will have to come up with innovative ways to encourage beneficiaries to seek care within their ACOs. For example, CMS might provide ACO patients with literature explaining the quality and cost-efficiency of the care they’ll receive through the ACO.  

Studies show that the way the information is presented has a significant effect on the number of patients who opt in or out. In one example, a group of patients was provided with personalized information about lower-cost Part D plans, while another group was provided with a link to a website that contained the same information. Those who received the personalized information were more likely to switch plans than those who were given the website link.

In general, while the success of ACOs may depend somewhat on minimizing “outside” care of their patients, it looks like there will always be some patients who would be able to obtain better care by utilizing multiple ACOs. For example, more than half of Medicare beneficieries currently have five or more chronic conditions that might need to be treated by more than one provider. Though some successful ACO-style systems seem to provide good, high-quality care for multiple conditions, the best specialists in any given market aren’t always involved in the same systems, so patients may need to step outside of their networks to get the care they need.