Care for a growing number of Connecticut residents is being directed by an Accountable Care Organization (ACO) and very few patients know it.
ACOs are large health systems of providers that have arrangements with insurers and government payers to lower the cost of your care. ACO networks can include a hospital, primary-care and specialty-care providers as well as other professionals and facilities.
In their best form, ACOs allow providers to work together, share patient information and assess members’ health needs. ACOs can ensure that patients get the care they need, and only the care they need, to stay healthy. But they can also reduce necessary care, avoid expensive patients, and end up costing us more.
Unfortunately, no one is watching.
If you think ACOs sound like the failed, old HMO model, you’re not alone. And ACOs are growing. Estimates place Connecticut ACO enrollment at 15% to 20%, among the highest rates in the nation. There are currently 14 Medicare and Medicaid ACOs, each covering over 300,000 Connecticut residents. There is no public reporting on ACOs covering privately-insured people in Connecticut.
As ACOs grow, so do concerns. To control costs, ACOs are generally reimbursed half the savings that they are able to generate on their patients’ care. ACOs only receive savings payments if they achieve a few quality metrics, but those are generally set very low and have little to do with health outcomes.
As with HMOs, this can lead to denials of necessary care and shifting away difficult or less lucrative patients. It is already happening in other states.
Rather than saving money, there are concerns that ACOs could increase costs. As ACOs increase consolidation in Connecticut’s already concentrated health care market, consumers will have fewer choices for their care and prices will rise. In 2016, Connecticut’s Medicare ACOs overspent by $45 million. Medicaid ACOs cost Connecticut taxpayers millions in their first year with no discernible improvement in quality.
We really know very little about how ACOs are treating Connecticut patients or how much money they are saving or costing us. Connecticut does not monitor or regulate ACOs. Since 1895, Connecticut has regulated insurance companies that take on financial risk, as it does with HMOs. ACOs take on financial risk, but today are not regulated here.
It’s not that ACOs aren’t regulated anywhere: Massachusetts has a certification program for ACOs and Vermont, with a small population, has created a statewide all-payer ACO.
Both Massachusetts and Vermont have long histories of protecting consumers and taxpayers with data-based policymaking, collaborative health reforms and trusted oversight. NCQA, a non-government independent leader in accreditation standards, certifies ACOs to complement care transformation and payment reforms.
As ACO enrollment grows and they exert more control over the care Connecticut residents receive and pay for, it is imperative that the state monitor their impact on our health, our costs, our taxes, and our care.
Ellen Andrews, PhD, is the executive director of the CT Health Policy Project. Follow her on Twitter @CTHealthNotes.
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