The A’s of ACA and ACO’s

Getting an MD after my name actually means I just figured out what MD, CHF, MI, AMA and a million other acronyms mean. The government similarly uses this type of “foreign language”: ATF, FBI, and everyone’s favorite IRS. Recently the government made things even worse by combining government and health words into single acronyms like the ACA and ACO’s.

The ACA and ACO are not the same thing with a typo. However they are related. I don’t have enough years left in my life to explain the ACA or Affordable Care Act (e.g. Obamacare). Suffice it to say that I “believe” the general objective is improved healthcare with reduced costs. There’s no doubt the present system is broken and expensive. In fact failures in healthcare are financially rewarded. If a patient comes to the hospital twice for the same problem – i.e. “something(s) or someone(s)” failed to fix the patient the first time – the hospital and doctor still get paid for both visits.

One way the ACA hopes to address this problem is with ACO’s which sound sneakily like the defunct HMO’s – did you get that? Here’s the translation: Accountable Care Organizations (ACO) are this decade’s version of Health Maintenance Organizations (HMO). An ACO is a group of doctors, facilities even insurers working together to care for a group of patients. And similar to yesteryears HMO’s, ACO’s only get a set amount of money from the government to take care of YOU (As in “you the reader” and not an acronym).

The theory is that by paying a fixed “amount” for your healthcare, everyone “in” the ACO will be motivated to keep you healthy for the lowest cost. The “best” ACO patient is 20 years old, non-smoker that walks to work. The ACO gets the fixed amount of money and doesn’t have to “spend any” on care. If you aren’t 20 and healthy, the ACO will want to help you be as healthy as possible so you don’t need expensive tests, interventions, and hospitalizations because these burn up the fixed reimbursement. That’s the theory anyway.

HMO’s failed. In large part it was because patients felt the HMO was only motivated to avoid the expenses of tests, interventions and hospitalizations. Patients didn’t believe that the HMO cared or helped them to be healthy. The ACA thinks they have a solution for that: it is NOT mandatory for patients to stay “in” the ACO. In other words, the ACO takes responsibility for you and gets paid accordingly, but you can still choose to go elsewhere (i.e. outside the ACO) to get healthcare. In essence the government would pay the ACO for your healthcare up front AND (not an acronym) the government would still be paying someone else for your healthcare if you chose to go eslewhere. Of course this begs the question – how the “A” in ACO’s or the “A” in the ACA are really going to mean anything.