JAMA editorial: ACOs reward big hospitals, but small practices, using mobile tech, are best bet to cut healthcare costs

By Jonah Comstock
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The Journal of the American Medical Association published a point-counterpoint set of opinion pieces yesterday on whether ACOs, as an experiment, should be declared a failure. Massachusetts General physician Dr. Zirui Song and Dartmouth Institute for Health Policy Director Elliot Fisher argued for ACOs by pointing to the shades of grey between different types of ACOs and suggesting ways to focus future ACO efforts. But the anti-ACO contingent, Drs. Kevin Schulman and Barak Richman of Duke University Schools of Medicine and Law respectively, argued that the concept was fundamentally flawed, and that mobile and telehealth tools were central to their reason why.

From Schulman and Richman's perspective, the problem is not the ACO model itself, but the fact that it puts the impetus for healthcare payment reforms on large hospital systems, who have a lot of buereaucracy and overhead. 

"Experts have long agreed that the health system needs to replace costly and technology intensive services with low-cost, capital-efficient alternative delivery models," they write. "Why then would the nation give the keys to reform to hospital-led delivery systems, the organizations with the most capital intensive and costly infrastructure?"

The best way to reduce costs, Schulman and Richman argue, is to keep patients out of the hospital, something that hospitals are not going to be easily sold on, no matter what incentives they're offered. They also argue that ACOs have encouraged large hospital systems to get even larger through acquisitions, leading to local monopolies that actually charge more for services.

And big hospitals are not well-equipped to take advantage of innovative technologies, the authors argue. That's where mobile and digital health tools, including virtual care, come in. The authors advocate a payment model that pays physicians and physician-led groups to keep patients out of the hospital, using new technologies to accomplish those goals.

"In rejecting the ACO hypothesis, CMMI efforts should be fully invested into developing those novel low-cost and highly connected platforms," Schulman and Richman write. "Payment models that target virtual rather than hospital infrastructures can spawn delivery models that involve telemedicine, diagnostic wearable devices, and the deskilling of clinical care practitioners including staff such as advanced practice nurses or even community health workers. Payment reform that centers around patients and services rather than costly hospital-led delivery systems can support workflow models that build upon 21st Century infrastructures, rather than the legacy infrastructures of the previous century."