The Patient Protection and Affordable Care Act defines an Accountable Care Organization (ACO) as a group of doctors, hospitals, or other health care providers that organize to "coordinate care to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors". While this effort is getting a lot of national play, and funding through a ""shared savings" mechanism, it is curious to me that the discipline of surgery is left out of the mix-completely.
Because of the enormous size of the surgical undertaking in this country – more than 40 million surgical procedures are performed each year – I argue that the redesign of surgical care processes, with resulting improvement in quality and reduced cost, could match whatever savings come from a focus on the chronically ill. Surgeons need to lobby for a structural and funding mechanism similar to the ACO to support our quality improvement efforts.
In order to generate federal funding for surgical quality improvement, we need an established model – a population based model-that helps us to define best surgical practices, to improve coordination of care between the inpatient and outpatient settings, and between surgical specialists and our primary care colleagues. By analogy to the current ACO initiative, such a model would create great interest at the level of the Centers for Medicare & Medicaid Services.
In Michigan, we have developed a population-based model that effectively addresses these issues. The Michigan Surgical Quality Collaborative (MSQC) includes 52 primarily community based hospitals interested in improving quality. This organization is funded entirely by the dominant third party payer in the state, Blue Cross Blue Shield of Michigan (BCBSM). We identify best performers in a variety of areas, make site visits to the best performers in order to identify best practices, and then disseminate the resulting information to the rest of the collaborative. This is done via a website or quarterly in-person meetings. Last year, BCBSM announced that they had saved $89 million in avoidable costs by virtue of the improved results seen within MSQC over a 3-year period, a remarkable return on investment. The high level objectives of the ACO approach were met, quality improved, and costs went down, substantially, but in surgical care, not primary care.
Several surgical quality collaborative groups now exist similar to MSQC, such as the Surgical Care and Outcomes Assessment Program, the Vascular Study Group of New England, Northern New England Cardiovascular Consortium, Michigan Bariatric Surgery Collaborative, Michigan Urological Surgical Improvement Collaborative, and many more that are developing. These groups provide a rich source of information about how to actually improve quality, information that is not available from any other mechanism that I know of, but financial support for these efforts is shaky at best. The burden of financial support is usually at the level of the individual hospital, but as we all know, times are tough in hospitals, and long-term participation is not guaranteed. Support by the third-party payer, such as BCBSM in Michigan, has been very successful, but whether this approach would work broadly across the nation is not yet known.
If one accepts that we have a population-based model that works, what mechanism could we suggest for which CMS would provide ongoing financial support? One suggestion is that CMS could offer financial incentives to urge the existing ACOs to participate in a regional improvement collaborative. This would represent an expansion of the current concept, but would perhaps be easier, since it would build on an existing structure. Another suggestion is that CMS consider the regional quality improvement groups as ACOs in and of themselves, with savings from the shared savings model flowing to the group’s administrative center, and subsequent distribution to individual hospitals.
Whatever the mechanism, the main point is that surgeons, via our emerging population-based models of collaboration, have enormous, and seemingly unrecognized potential to "bend the cost curve." There is now no federal strategy that would support these efforts, but one is much needed. The American College of Surgeons should use its lobbying influence to argue this point.
Dr. Campbell is the Henry King Ransom Professor of Surgery, University of Michigan Health System, Ann Arbor.