Can Proactive Value-Based Care And ACOs Have An Impact On Amputation Prevention?

In many countries, there is a single payer system, in which the government pays the cost of health care and the providers are on salary. In this model, there is no billing as providers merely provide the services mandated by the government for patients. Great Britain, Canada and Australia are examples of countries that have single payer systems. 

However, in other countries, there may be a varety of payment models for health-care services. In the United States, varied payment models influence whether the care will be reactive or proactive. The reactive models include fee-for-service, health maintenance organizations (HMOs) and preferred provider organizations (PPOs) while the proactive model is a relatively new payment system called “value-based care.”

The predominant model in the U.S. is the “fee-for-service” model. In this reactive care model, which is based on volume, the provider bills an insurance company or Medicare, and receives payment for each “allowable” service. The more “allowable” services that one provides, the more income the practice generates. The insurance companies are satisfied with the fee-for-service model because their actuaries have established continuing profit levels for them. This reactive model has a focus on profit like most businesses but in this case, profit creation occurs by managing the health of their insureds. This deals with people and their lives, not products like shoelaces. Often, there is a perception that insurance companies view people just like shoelaces, a commodity on the marketplace. 

In the fee-for-service model, having a patient with diabetes can be beneficial for the practice. Why? There is a recognition that the patient is likely to have health problems in the future and the return visits represent cash flow to the practice. There is no financial impetus toward prevention as it is contrary to the financial health of the practice.

The new payment model growing in popularity in the U.S. is “value-based care.” Accountable Care Organizations  (ACOs) practice this proactive model, which is based on value rather than volume.  

Accountable care organizations are groups of doctors, hospitals and other health-care providers, who come together to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in delivering high-quality care and spending health-care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.¹

Thirty-five of the 37 ACOs participate in the “Next Generation” model of health care delivery. That model offers an exciting opportunity in accountable care, one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.²

These ACOs reduced Medicare spending by a combined $668.6 million in 2019 according to the data.³ Only two of the ACOs did not achieve savings. The 37 ACOs earned a combined $461.9 million in incentive payments from the Centers for Medicare and Medicaid Services, (CMS) for meeting financial and quality targets. This means the program resulted in a $204 million savings.³

There are 41 different variations in the ACO model based on quality of performance rather than total billable services.¹ Currently, there are more physician-led ACOs than there are hospital-led or jointly-led, which is different from early years of the ACO movement. Of all 995 ACOs currently active, 425 (43 percent) are physician-led, compared to 274 hospital-led and 294 jointly-led.⁴

Overall, however, in the proactive value-based care system, there is more of an alignment between financial incentives, prevention of comorbidities from diabetes and reducing the cost of care. In contrast, the “fee-for-service” model has providers in more of a reactive mode with fees tied into the treatment of diabetic foot complications (including neuropathy, ulcers and amputations) as well as other comorbiditiies of diabetes that include retinopathy, end-stage renal disease (ESRD) and peripheral arterial disease (PAD).

In the ACO model, providers would address the foot health of every patient with diabetes in a proactive manner and the patient would receive a comprehensive diabetic foot exam yearly. Any risk(s) identified that might contribute to the development of a foot ulcer would immediately inspire referral to the appropriate member of the interdisciplinary team for evaluation and ameloriation of the risk(s). The care might include X-rays, offloading insoles, diabetic shoes,  ongoing foot care and surgery if indicated to correct a bone, soft tissue or nail deformity. The patient would undergo follow-up and monitoring. 

In the fee-for-service model, patients may not receive the yearly comprehensive diabetic foot exam, risk(s) for developing a foot ulcer may remain unidentified, and as a result the patient may develop a foot ulcer necessitating further treatment. The care in this case would be substantially different in that it may include hospitalization, X-rays, magnetic resonance imaging (MRI), wound cultures, oral or intravenous (IV) antibiotics, hyperbaric oxygen, inpatient surgery, multiple outpatient wound debridements, amniotic grafts, negative pressure wound therapy (NPWT), offloading devices and the need for the patient to perform dressing changes in the home and travel for multiple follow-up doctor visits. In the worst case scenario, the patient may need an amputation.

The difference between being proactive versus reactive highlights the benefits of the ACO model in patient quality of life and the cost of care.

Patients with diabetes should feel confident that the care they receive from providers in an ACO will keep them healthy and out of the hospital because that is how the providers make a profit. This incentive is a key factor that can help prevent people with diabetes from developing ulcers that can lead to amputations.

Not all podiatrists will embrace working in the ACO model. However, it is clear that the real opportunity for podiatry in the ACO model is to be proactive in the care for patients with diabetes and support prevention. In 2021, podiatrists have a genuine opportunity to bring value to an ACO because the ACO philosophy of prevention works well with the education, training and abilities of our profession to provide proactive preventive care for the foot and leg. There is no other foot health-related profession that can deliver the quality preventive care that a podiatrist can deliver. Accordingly, for those podiatrists who dare to embrace being proactive and see the value of prevention for the lives of their patients with diabetes, a hard look at the opportunities aligned with the ACO model is in order. 

Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” which are available at www.amazon.com.

References

1. Centers for Medicare and Medicaid Services. Accountable care organizations (ACOs): general information. Available at: https://innovation.cms.gov/innovation-models/aco .  Published January 14, 2021. Accessed January 18, 2021.

2. Centers for Medicare and Medicaid Services. Next Generation ACO Model. Available at: https://innovation.cms.gov/innovation-models/next-generation-aco-model . Updated January 25, 2021. Accessed January 28, 2021.

3. Paavola A. 35 next gen ACOs achieved savings, bonuses in 2019. Becker’s Hospital Review. Available at: https://www.beckershospitalreview.com/finance/35-next-gen-acos-achieved-savings-bonuses-in-2019.html . Published January 14, 2021. Accessed January 18, 2021. 

4. Muhlestein D, Bleser WK, Saunders RS, Richards R, Singletary E, McClellan MB. Spread of ACOs and value-based payment moldels in 2019: gauging the impact of pathways to success. Health Affairs. Available at: https://www.healthaffairs.org/do/10.1377/hblog20191020.962600/full/ . Published October 21, 2019. Accessed January 28, 2021.