ACO pilot fails to rein in cost on cardiovascular imaging, procedures

An accountable care organization (ACO) pilot failed to see reductions in discretionary spending for cardiovascular nonessentials, researchers found. The study published online Oct. 20 in Circulation noted that care did not diminish for those patients for whom procedures were essential, however.

The research team led by Carrie H. Colla, PhD, of Dartmouth Institute for Health Policy and Clinical Practice in Hanover, N.H., used Medicare data for 10 groups participating in the pilot from before and after implementation of the Physician Group Practice Demonstration ACO and compared it to nonparticipating groups from the same regions.

The team reviewed discretionary and nondiscretionary carotid and coronary imaging and procedures from 2002 through 2004 (before) and 2005 through 2009 (after) and compared these findings between the ACO and non-ACO groups and to the before and after implementation periods.

Colla et al defined nondiscretionary procedures as ones performed on patients who had symptoms of coronary disease, stroke or transient ischemic attack within less than a year.

No statistical differences were determined on the whole between ACO and non-ACO practices toward discretionary carotid or coronary imaging or procedures and they likewise found little difference between spending before and after implementation.

Similarly, little change was seen in nondiscretionary carotid or coronary procedures that would indicate poorer quality of care was given to patients who needed it.

“However, we found no evidence to suggest that an early ACO Medicare demonstration had any effect on the utilization of discretionary cardiovascular care. Our study suggests that better tools and implementation strategies may be necessary to limit growth in discretionary, specialty-related spending under ACO care contracts,” they wrote.

Colla et al could not directly account for why spending on nonessential procedures and testing did not decrease in spite of incentives, but they did consider that ACO spending policies may be more focused on primary care treatment patterns rather than on specialties. This was echoed by Karen E. Joynt, MD, MPH, of Brigham and Women’s Hospital in Boston.

In an editorial, Joynt wrote that focusing on primary care alone oversimplifies the issue. Joynt suggested that in order to see cost savings at the cardiovascular specialty level, specialists need to become more involved in the process, working with others to create innovative care solutions.

“As primary care physicians under ACOs attempt to cut costs without inappropriately cutting high-value services, input from specialists is essential,” Joynt wrote. “The relationships for collaborative decision-making with both patients and primary care physicians must be built before they can be utilized.”

Colla et al noted that cardiovascular care can achieve cost reductions if properly targeted and incentivized. They suggested considering new tools and a specialty focus to achieve future cost savings.