The implementation of pilot accountable care organization (ACOs) has demonstrated an inability to limit the use of discretionary or non-discretionary cardiovascular care in ten large health systems, according to a study published Oct. 20 in Circulation.

Designed within the Medicare program, ACOs are groups of physicians and other providers who agree, as a unit, to provide high-quality care at costs that are lower than projected, and in doing so are eligible to share in the monetary savings. It is the general hope that providers participating in ACOs will cut costs by reining back on discretionary care where it is safe and appropriate, all while holding onto current levels of provision of non-discretionary, high-value care. In a new study principal investigator Carrie Colla, PhD, Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, and her colleagues sought to determine whether these results were in fact taking place.

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Employing evidence from the Physician Group Practice Demonstration (PGPD), a pre-ACO demonstration project on which much of the ACO program is modeled, Colla el al. compared the use of cardiovascular care before and after PGPD implementation, studying both discretionary and non-discretionary carotid and coronary imaging and procedures. The authors ultimately found that despite the investment of millions of dollars into the infrastructure, there was no difference in trends in utilization of either discretionary or non-discretionary cardiovascular imaging or procedures between the PGPD groups and local controls. The groups were similar in both the pre-PGPD period and the post-PGPD period on all metrics of utilization that the authors examined.

The study authors offer a number of suggestions as to why the program is failing to cut costs, including a heterogeneity within systems, a focus on primary care, and an imbalance between the financial incentives on the side of the savings versus the side of revenue.

According to Karen Joynt, MD, MPH, Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, little formal involvement of specialists may have also played a significant part. Ultimately, Joynt argues, “Cardiovascular clinicians must be involved and engaged if we are to meaningfully increase the value of health care delivered in this country. With such a large proportion of health care spending coming from cardiovascular care, ACOs are unlikely to move the needle, particularly in a safe and efficient way, without meaningfully engaging these clinicians. The study … should be a wake-up call to those ACOs who have not yet developed a strategy for doing so, and a reminder to those who have, that specialists need to be at the ACO table.”

Keywords: Physicians, Health Policy, Specialization, Motivation, Boston, Investments, Accountable Care Organizations, Medicare, Primary Health Care, United States, Group Practice

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