Patient looking and form with doctor The accountable-care organization model rewards physiciansand health systems for providing quality care, rather than justquantity. (Photo: Shutterstock)

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Finding the most efficient health care delivery system mayrequire a mix of both primary care and specialist care, a new study suggests. The report, published bythe Journal of the American Medical Association Network, looked atAccountable Care Organizations (ACOs), a delivery model created aspart of the Affordable Care Act. The authors wanted to betterunderstand the relationship between specialist visits and lowerspending among ACOs.

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The study noted that primary care has received a lot of emphasiswith ACO health systems, on the theory that having a dedicatedprimary care provider will help patients manage and prevent healthconditions.

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Related: Unmet expectations spark overhaul of MedicareACOs

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ACOs seek to better coordinate care, since coordinated care isconsidered to be less costly. The model rewards physicians andhealth systems for providing quality care, rather than justquantity. The ACO model is overseen by the Centers for Medicare andMedicaid Services, which rewards health systems financially forhitting coordinated care benchmarks.

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But the researchers noted that not much research had been doneon how specialist care affected the efficiency of ACOs, so thisstudy explored that question, using data from 620 ACOs during afive-year period, 2012-2017.

Finding the sweet spot

The report found that too much or too little specialist carevolume tended to increase costs for ACOs. “We found thatexpenditures were lowest for ACOs with a balanced specialistencounter proportion (40 percent to less than 45 percent), whereasACOs at the specialist encounter proportion extremes (less than 35percent and 60 percent or greater) had the highest expenditures”the study said.

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The costs associated with the two extremes were different: thosesystems with relatively few specialist encounters had higher costsfrom ER visits, while those ACOs with high percentages ofspecialist encounters had higher rates of expensive procedures suchas MRIs.

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“These findings suggest that ACOs that provide office visitsthrough a balance of PCPs and specialists may be better positionedto achieve utilization rates that are consistent with lower costs,compared with ACOs that provide office visits through a more skewedPCP and specialist distribution,” the study said.

Not enough incentives for specialists?

The researchers further concluded that ACOs with littleparticipation from specialists may especially want to try a morebalanced approach. “We speculated that patients seen only orprimarily by primary care providers may receive suboptimal care,especially if they are chronic-care, high-risk patients,” saidVishal Shetty, a University of Massachusetts Amherst Ph.D. studentin the School of Public Health and Health Sciences, and one of thestudy's authors, in an article published by MedicalXpress.

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The study suggests that ACOs should create more financialincentives to bring in specialists. “There aren't strong incentivesas it stands now for specialists to join ACOs,” Shetty said in thearticle. “Fee-for-service reimbursement is still a higherincentive.”

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