Newswise — In a study of 10 large health systems, Dartmouth investigators Carrie H. Colla, PhD, Philip P. Goodney, MD, MS, and Ellen R. Meara, PhD, and others from Dartmouth and the University of Michigan found that implementation of pilot accountable care organizations (ACOs) did not limit spending on discretionary or non-discretionary cardiovascular treatment for patients. Published in Circulation, their paper demonstrates that health systems need to directly consider specialty care in order to achieve meaningful savings. The paper is titled, "Implementation of a Pilot Accountable Care Organization Payment Model and the Use of Discretionary and Nondiscretionary Cardiovascular Care."

"We found that, when an ACO payment model was implemented, evidence-based treatments for patients with cardiovascular disease, such as heart attack or stroke, were provided consistently," said Colla. "That's a good thing. However, we also found that discretionary tests and procedures, such as stress tests for people without symptoms, were still being commonly ordered. We hypothesized that pilot ACOs would target these discretionary treatments to help lower spending, but that didn't happen. For ACOs, which need to focus on limiting spending on discretionary treatments, this is a missed opportunity."

The intervention group in this study was composed of fee-for-service Medicare patients from 10 groups participating in a Medicare pilot ACO organization called the Physician Group Practice Demonstration (PGPD). The controls were organizations in the same region without pilot ACOs. The study considered cardiovascular care before and after implementation of the PGPD.

"We looked very closely at our results, wondering if perhaps some pilot ACOs fared better than others," explained Goodney. "However, for every ACO in the study that spent a little less, another ACO spent a little more. As a result, ACO providers as a group didn't limit spending when compared to the control group of providers without pilot ACOs."

"To achieve meaningful savings, ACOs need to consider specialty care directly," said Meara." This should be in addition to their focus on the spending by primary care physicians. It's clear that more savings are possible, but it's going to take hospital leaders involving the entire care team."

Looking forward, the Dartmouth team suggests that a more global approach within health systems that involves everyone from primary care physicians to specialists is needed to realize potential savings in an ACO model.

Drs. Colla and Meara are health economists at Dartmouth and The Dartmouth Institute for Health Policy and Clinical Practice. Their work is funding by NIA R21 AG044251 and NIA PO1AG01978. Dr. Colla is a member of Dartmouth's Norris Cotton Cancer Center. Dr. Goodney is a vascular surgeon at Dartmouth-Hitchcock Medical Center and an associate professor of surgery at Dartmouth's Geisel School of Medicine. His work is funded by NHLBI 1KO8HL05676-01.

About Norris Cotton Cancer Center at Dartmouth-HitchcockNorris Cotton Cancer Center combines advanced cancer research at Dartmouth and the Geisel School of Medicine with patient-centered cancer care provided at Dartmouth-Hitchcock Medical Center in Lebanon, NH, at Dartmouth-Hitchcock regional locations in Manchester, Nashua, and Keene, NH, and St. Johnsbury, VT, and at 12 partner hospitals throughout New Hampshire and Vermont. It is one of 41 centers nationwide to earn the National Cancer Institute's "Comprehensive Cancer Center" designation. Learn more about Norris Cotton Cancer Center research, programs, and clinical trials online at

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NIA R21 AG044251; NIA PO1AG01978; NHLBI 1KO8HL05676-01; Circulation