ACOs & cardiology: Trend hints at some alignment

Cardiology may be a step ahead of some other specialties in participation in Accountable Care Organizations (ACOs). An analysis of self-referrals to specialists found that the percentage of new patient self-referrals in cardiology was lower than the national norm for both Medicare and private insurance beneficiaries.

The ACO model is designed to improve the coordination of care and lower costs by making a primary care physician the point person in a patient’s care. The primary care physician provides the bulk of services and when necessary, refers the patient to specialists who participate in the organization. High rates of self-referral threaten to weaken the incentive for specialists to collaborate, though, and may undermine the potential to save on costs, observed Oluseyi Aliu, MD, of the University of Michigan Medical School in Ann Arbor.

Aliu and colleagues analyzed data from the National Ambulatory Medical Care Survey from 2000 to 2009 to determine the magnitude and trends in self-referrals to specialists. They published their results in the January issue of the American Journal of Managed Care.

The analysis focused on new patient visits to the most commonly listed specialties: cardiology, neurology, otolaryngology, dermatology, orthopedics, urology, general surgery, ophthalmology and obstetrics/gynecology. The survey included type of primary payer, which allowed Aliu and colleagues to study trends by payer as well.

They analyzed 32,784 new visits to specialtists from 2000 to 2009. Medicare served as the primary payer in 19 percent of visits, and private insurance in 59 percent. The weighted absolute number of self-referral visits remained generally flat over the study period, from 3.1 million to 3.9 million for Medicare and from 13.3 million to 13.7 million for private insurance.

Overall, the trend in self-referrals declined. In 2000, about a third of self-referral visits were paid through Medicare and private insurance. By 2009, that dropped to 19 percent for Medicare and 24 percent for private insurance.

“[I]t appears that self-referred visits, although stable in magnitude, constitute a generally declining proportion of both increasing overall referrals and ambulatory visits in the U.S. healthcare system,” they wrote.

The percentage of self-referrals in cardiology in 2009 was 14.4 percent for Medicare and 13.2 percent for private insurance. By comparison, the 2009 percentage for obstetrics/gynecology was 45.2 percent and 47.2 percent, respectively.

The findings may help policy makers identify those specialties that may be slow to embrace new models of healthcare delivery. “[T]he differential self-referral rates provide informative data on where efforts may need to be focused in order to achieve the goals of improved care coordination and cost containment,” they suggested.