The ACA, the ACO and the Complex Care Patient

The ACA, the ACO and the Complex Care Patient

Editor’s Note: This idea started with a tweet last weekend by Dr. Terri Lewis, who has been writing for and speaking about how the health care system fails the chronically ill patient, in particular. We asked her to write about this for The National Pain Report .Dr.Lewis is the daughter and the mother of persons who suffered and suffer from chronic pain.

A basic premise of the Affordable Care Act (ACA) is that preexisting conditions will not result in denial of care.  Theoretically, the formation of networks can insulate costs of care from runaway costs assigned to the minority of users who consume the greatest portion of total plan costs.

How well is this working for persons whose complex health profile includes chronic pain care?

Historically, physicians have not been employees of hospitals. Until the 1990s, the majority of physicians were members of independent or solo practices who enjoyed practice privileges through local hospitals. Since then, waves of hospital mergers have created metropolitan hospital organizations that have formed monopolies by purchasing physician groups.  In rural areas, insurance companies have formed monopolies by controlling the enrollment of providers and capitating the numbers of specialties who can participate. Between hospital mergers and the formation of hospital owned health insurance groups, physicians are integrated vertically into health care systems in a new configuration ostensibly designed to improve care and reduce costs. While this seems like a useful approach to improving care while reducing cost for expensive patients under the Affordable Care Act (ACA), things may not be what they seem.

The ACA was designed around the premise that Medicaid would be expanded to supplement reimbursement for persons under a certain income threshold.  At this time 19 states still have not adopted Medicaid expansion, creating a significant community coverage gap.  Despite this, the ACA incentivizes health plans to form narrow networks, a strategy encouraged by CMS regulations. Some definitions-

Medicare Shared Savings Program (MSSP) is the set of CMS guidance regulations located at the link below.

Accountable Care Organizations (ACOs) are groups of providers (hospitals, physicians, other providers) who join together for purposes of a Medicare fee-for-service incentive program. ACOs are paid to “reduce costs” for treating their patients. While this seems like a reasonable goal, the ACO system has a number of risks-

  • Some plans allow the consumer to pick from a menu of alternatives ACO plans based on what they believe their needs will be. Annually, the consumer can change their plan assignment and may have to change physicians as a result.
  • Most consumers don’t “enroll” in an ACO – they are assigned to an ACO based on the patterns of their utilization. At the end of the year, if a patient happens to have had a bulk of their care (measured by either service counts or dollars of Medicare claims), from physicians who are members of a particular ACO, then that patient is assigned to that ACO.
  • Not only do many patients not enroll in ACOs; they might not even be aware of them, as assignments may take place after the fact.
  • ACOs receive bonus payments based on the total amount Medicare pays for care of those patients. That total includes allcare those patients receive from all providers – specifically, including providers who are not members of the ACO. Bonuses are based on reducing total costs relative to what would be expected using a risk-adjusted cost based on each patient’s health status. Here, reduced costs mean reduced services or, less care.

Providers are incentivized to encourage patients to utilize less care – say, to recommend fewer surgeries, fewer hospital stays, less frequent follow-up visits, and so on. ACO participants can refer patients to other participants in the same ACO when another type of care is needed, so that the ACO can deal with the patient in a consistent manner. There is no follow-up by the ACO to determine whether care alternatives achieve necessary purposes because they are measuring reduced utilization not better outcomes to care.  Patients are left to their own devices to manage these processes without the substantive information necessary to make truly informed choices about their treatment.

How is an ACO is supposed to reduce patients’ utilization of health care in a fee-for-service system?

  • ACOs control the number of providers who can participate in the provision of services within a geographically bounded area.
  • Where the ACO controls a large percentage of the available providers, it gets a lot easier to reduce patient utilization by controlling provider participation. ACOs that “own” most of the specialists in a geographic area have a much easier time controlling utilization.
  • Providers who serve large numbers of complex patients may be denied the opportunity to enroll, forcing their patients to redistribute to other practices, or leaving them without a reimbursable service entirely. ACOs that have met their capitation objectives are unlikely to admit additional physicians who might provide more appropriate care for specific individuals.
  • It becomes a lot easier to guide patients to the level and type of utilization desired – which is, for purposes of the Medicare Shared Savings Program, always less
  • It is easy to enforce referral and utilization policies on physicians who are employees of a group running the ACO, rather than simply independent businesses who happen to join an ACO at a given moment in time.
  • ACOs that want out of certain lines of business they perceive to be risky can simply cut those services from their menu of care by delisting physicians.

In other words, the Medicare Shared Savings Program encourages hospitals and physicians of different specialties to join together in order to encourage patients to use less health care.

How does the patient fare under this scheme?

  • Because ACOs control the number and type of physicians who participate, providers may not have specialties that match the needs of the populations to be served, which forces patients to seek treatment outside the system on a cash basis. Where there are no funds, there is of course no reimbursed service.
  • There is no requirement under the ACO for the enrolled physician to accept eligible patients with complex care needs. To be eligible for bonuses, physicians find themselves managing their overall patient risky profile of services across their practice rather than managing the care needs of patients.
  • Patients with long standing physician relationships may be forced to change providers when they are denied the opportunity to enroll. This forces patients to redistribute to other practices in order to seek care from someone unfamiliar with their history and needs.
  • The lack of a physician may force the patient to seek services from local emergency rooms which leaves complex care patients vulnerable to less than appropriate care. Continued care failure at the ER level may result in wrong diagnosis, under treatment, and cause the patient to refuse to seek necessary treatment entirely. This can result in patient stigmatization, labeling, and other negative consequences such as lawsuits lodged against patients who cannot afford hospital fees.
  • Rural ACOs “own” most of the specialists in a geographic area control utilization in ways that may result in less than optimal care because the specialists may have no experience with a patient’s health condition.
  • Patients are rarely informed about the conditions of participation for their treating physicians who have affiliated with ACOs.
  • The responsibility to find appropriate physicians within this scheme is left to the patient – there is no obligation for the ACO to modify their practices to insure that enrolled are served.
  • The boundaries of the ACO configuration may require patients to travel very long distances for care, undermining the very premise of affordable, accessible care provided where and when needed.
  • Patients with chronic pain may find themselves lost at sea in this system of reduced care as state pain laws redirect precious services and require more frequent interaction with their treating providers – a direct conflict with ACO requirement to reduce utilization.

Who manages this system?

CMS is responsible for Medicare portion of ACOs.  State Medicaid agencies are responsible for administering contractor ACOs under the Medicaid portion of this plan.

What about drug plans?

CMS administers the drug formulary.  Drugs are dispensed according to the purpose for which they were approved by FDA.  This is referred to as ‘covered uses.’ State Medicaid plans adopt the formulary.  Patients may have to adopt prescriptions that are less than optimal depending on how the ACO chooses to administer their portion of the plan. An appeal process is available but lengthy and difficult for the patient to manage.  Medicare will not provide patients with information about covered uses, which makes it difficult for both patients and care partners to develop an appropriate medication plan.  Multiple appointments may be necessary to deal with this issue, placing the individual at odds with the physician’s risk ratio requirements.

So, let’s take a real example.

Patient X is 33 years old, assigned to a Tennessee operated ACO as a dual eligible, receiving both Medicare and Medicaid.  Dealing with a lifelong spinal injury, his needs are complex. Given his complexity, he finds dealing with physicians to be a consistently unsatisfying interaction. Having already had three major surgeries, he requires a fourth due to broken hardware installed during his third surgery.  He will require monitoring, future surgical procedures, pain management, behavioral health, and lifelong wellness supports.

New to the ACO, his surgeon requires primary care support, pain management, behavioral health support, and smoking cessation as preparation for a pending major surgery.  On his own, he makes multiple phone calls to attempt to obtain a primary care physician to coordinate a program of care with his surgical center – a major hospital 100 miles distant.  Unknown to him, the ACO has capitated physician enrollment within his service area.  Available primary care physicians have in turn, limited the number of patients they will see attached to his ACO in order to manage their risk ratios.  This allows them to allocate risk across their patient group and preserves their ability to be eligible for bonuses. No primary care physician associated with his ACO will accept him for care.  Unaffiliated primary care providers will assess him $220.00 per visit out of pocket.  On Social Security disability, that is not affordable.  His public health clinic will not prescribe for either his pain management or behavioral his health needs. His behavioral health center doesn’t treat people with chronic pain having no specialists on their staff.

His surgical needs are complex and urgent.  Without primary physician support, he cannot obtain the care support he needs for coordination of services and pain management.  Rejection of services is entered into his medical record as an inappropriate patient who is too complex to serve.  State pain laws have resulted in rejection for appropriate pain management support for complex chronic pain management needs.  In his state, under current regulations changes, primary care physicians will not prescribe for chronic pain; interventional pain management specialists will not accept a patient who (properly) rejects interventional pain procedures.

Eighteen months into this situation, this individual filed complaints with CMS and state Medicaid over their failure to manage the ACO contractor for the state in which he lives.  Persistent phone calls over a four-month period resulted in a telephone meeting to assign service providers.  From this a primary care provider 100 miles away was identified.  The primary care provider is co-located with a behavioral health care provider.  After a first visit, both entities agree that their service is too far away to be useful to this patient but they can see him about every 3 months.  Both entities refuse pain care management but make suggestions for a new palliative care provider (again 100 miles away) – who cannot provide services because his death is not imminent within a projected 12-month period.


No surgery will be performed without wrap around supports – it’s perceived as riskier than allowing this patient to remain underserved.  Worse, nobody is held responsible for this design failure except this patient – who has absolutely no control over the outcome.

As Robert Book (Forbes, 2016) notes, “It is highly ironic that a law proposed, in part, because of the allegation health insurance companies were increasing their profits by denying care to patients – is now the means by which the federal government pays physicians to, in effect, deny care to patients.”  In an arena of opiophobia and changing state regulations, the result for patients with complex care needs is exactly like lighting a match and flipping it into a pile of leaves.

Keep your ears pealed for this problem advocates. Now more than ever you are needed.  My next article will address potential courses of action.



CMS (2015, December). Medicare Shared Savings Program Shared Savings and Losses and Assignment Methodology Specifications Applicable Beginning Performance Year 2016, Version 4 Retrieved from

Book, R. (2016) Why Are Hospitals Buying Physician Practices and Forming Insurance Companies? Retrieved from

Book, R (2016). ACA ‘Savings’: Paying Doctors and Hospitals Bonuses to Deny Care to Patients. Retrieved from

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Authored by: Terri A Lewis, PhD.

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Kathy Cooper

Thank You Dr. Lewis,

In New Mexico the ACOs are really cracking down on any Healthcare for the complicated Patients. The Local Media continues to run “News Articles” that are Advertising for the Industry, which in this area consists of a Monopoly Religious Non Profit. This Monopoly has bought up most of the Medical Practices, while the few Independent Doctors have retired or left the State. It is likely the Doctors in the System are subject to gag orders or unable to counter any of this misinformation. They do no even acknowledge pain, they simply change the subject.
I see sick people everywhere, the Pharmacy, struggling along the roads, and streets, many have nothing, and are elderly. They are everywhere, in the small towns, and the big city. They are not mentioned in the Media, they simply do not exist. This is while they increase funding for Tourism, and pay big money for Public Relations. Healthcare has the same consistent narrative, about how expensive it is, while they promote the “Investment opportunities.”
There is a serious disconnect between reality and the projected by the Media Disneyland version. I see them every time I go to town, at one time I would pass the time by talking with these people, their stories are truly frightening, they could be any of us, without the resources to deal with a health issue and non existent employment. I am truly frightened by the lack of empathy and the utter despair on their faces. I just don’t understand how we could live in a Society that allows this and actually promotes it. In the last 2 Decades it has gotten only worse.

Stephen S. Rodrigues, MD

I just joined an ACO but this is not where the key problems and fact breaches are located. This is just a few upper class physicians who think they can figure out how to mend chaos without considering all of the historical evidence. Yes, I’ve sent Mr Conway and his personnel in CMS many emails outlining this breach in all of the fundamental law of nature. These hard science facts that must be repaired - FIRST. Any constructs placed on top of this faulty foundation will also fail to serve and protect our elderly from imminent harm. These breaches began to take shape over 100 years ago but culminated in a sinister event which occurred in 1968. A group of surgeons got permission to remove a “knee joint” for “knee pain.” Amazing was this surgical procedure, in reality, crossed the line from the domain of man’s fallible creations and that of the perfection of God’s creation. That was the year man began to play and perpetrate being Gods. These surgeons then had to infect medical educators and policy makers in the Federal Government with this deception. So now playing Gods is legalized and sanctioned as good “standard of care” by HHS. This is an interesting marketing idea to appease people’s dissatisfaction of poor clinical outcomes. These are cover ups of many lies. 32 years in medicine, I have concluded our medical educational elite dropped the ball to allow this rigged system to be setup under our noses. The Rig vs The Facts: The science charade: Pain is located in your skeleton or nerve parts ie joints or spine. Pain can be seen on the MRI. Pain comes from Osteoarthritis, Degenerative Disease, bone-on-bone, slipped disc, wear and tear of cartilage. Pain problems can be fixed by removing the ugly parts and wedging in shiny new titanium parts. There are no other standard of care options we recommend, except to take your painkillers, suffer or go to surgery. We have studied these problems extensively and the longer you wait to get the surgery the worse your pain and life will get. The correct science: The most common primary location of all aches and pains can only be located in the soft, connective and muscular tissues of the body. The exact pathology of your pain is within muscle bundles. The only way to eradicate the pain from muscle tissues is with hands-on physical therapy. Hands-on PT comes in a spectrum based on Rachlin, Gunn, Simons and Travell: Massage, Chiropractic care, filament and hypodermic intramuscular needling. The readily available spectrum of care works the best. (These are not being offered to you by this sinister minded designed system.) It is impossible, by the laws of biology, for the skeletal, CNS or blood to be the primary pathological location of pains. It is a criminal act, although now “legalized” to suggest a “standard” treatment that defies science facts. It is a betrayal and a sinister action against another human being to offer a treatment which… Read more »

Terri Lewis PhD

“The Medicare Shared Savings Program, for example, saw small benefits: 114 Accountable Care Organizations (ACOs) in the first year of the program, only 29 succeeded in generating a combined $128 million in savings; only four ACOs opted to share in upside-downside risk, and half of those shared in losses.[1] Most concerning of all, however, is that the ACOs pressured HHS to waive the quality improvement benchmark standards, and to allow ACOs to continue to participate only in upside risk sharing. This means that ACOs will continue to share in any savings they generate with no risk of shared losses, yet they are under no obligation to produce any quality improvements.

Likewise, a recent RAND study has indicated that value based purchasing (VBP) programs create “modest” improvements in quality of care, but acknowledges that studies with better methodology tend to demonstrate less correlation between VBP programs and improved quality outcomes.[2] It is possible that VBP best lends itself to care of certain Diagnostic Related Groups over others.”

Tim Mason

Thank you Dr. Lewis for writing this informative article. It appears that the best is yet to come.”Keep your ears pealed for this problem advocates. Now more than ever you are needed. My next article will address potential courses of action.”
I can hardly wait to read these future articles.
I feel so “enlightened” now.

Richard Oberg M.D.

Great write up Terri. Doc Anonymous is absolutely correct. The sad thing about this is that when patients like us with good private insurance and are essentially ‘palliative care’ and are having difficulties getting appropriate chronic pain med care for the same reasons Doc Anonymous states we’re all in trouble.

Whatever the reasons, right or wrong, physician practices are ‘dumbing down’ to those relatively healthy patient populations with simple maintenance requirements like getting routine labs and simple scripts refilled - as many as can be packed into an office every day.

The ‘old school’ people who took any and all comers is at an end except for very few remaining areas of the country. It’s truly abominable and not at all what health care is supposed to be about. Even our 501c3 city/county owned hospital is dictating what its physician employees will care for when it’s supposed to provide care for everyone. I don’t see any of this resulting in anything good for seriously ill patients since most of our state bureaucratic healthcare managers could care less. You’d think they worked at the behest of someone other than the taxpayers, wouldn’t you?


Recently found out that my doctor is in an ACO. thank you for this article which illuminates this so well. not a good time in history to be a baby boomer with Medicare. but I am grateful I have SOMETHING. everyday, where I live, I see people who have nothing, not even a place to live. thank you Dr. Lewis for anothe helpful article. I am printing it.

Jean Price

I don’t believe our country will ever have a patient oriented health system overseen and created by government until government themselves has to abide by it! They don’t have a clue what they are doing to people and they don’t have this type of coverage themselves so they have no need to further perfect the poor systems they mandate for others! This is really criminal and not at all in the best ethical sense of what our country is about! Look at VA and TriCare if you have any doubts! Why did anyone think they would or could do better?! They have no accountability and no personal experience now or after they retire! They must have relatives who have these systems…but they probably long ago disowned them, I know I would!


The narrative really helps put things into perspective. Thank you Dr Lewis 🙂


patient X needs to move out of that state sorry to sound harsh but if he really wants quality of care being in that state (Tenn) it is impossible to get it from his story

also on many web sites with issue issue of pain management Tenn. is harsh many others have same issue

I also had a failed neck surgery ,but I get pain management it is low dose but better than nothing also I have PTSD from neck surgery long story my GP figure the surgery messed me up and sent me to a mental health source outside of the Hospital health care system that I am part of healthcare system has mental health care also
In my state WI Scott Walker shortened Medicade booted married couples off…. my hubby is a victim ,our income is right at the cusp we can not afford private insurance from the Obama web site even with help deductibles are so high he would not be able to get care anyway ever…………… what is the point of having insurance at all You have a bill every month then have to pay to be seen and then have to pay a $3,000 deductible hubby had accident broke neck and back still works 40hrs a week , as he ages he is in need of pain management …

Vickie Cawley

Thank you so much for writing this article. Some questions I had about visits with my primary care physician have answers now. I am a complex care patient that has been without help for 2 years now. I have had back surgery, gall bladder surgery (in my late teen years I developed gall stones that were not found until my mid twenties and when they were finally found and I had surgery my system was so damaged I went into a coma and was not given much chance of coming out of. Now I suffer from pancreatitis because of the damage and am accused of being a alcoholic when I require care. I no longer try and get help when I have a flare and suffer through days of excruciating pain.), 10 sinus surgeries because of allergies to mold, hysterectomy, 2 surgeries on my intestines because they kink up causing another host of problems and my thyroid was removed due to being covered with cold nodules. There have been other surgeries I haven’t listed. I am allowed to have blood work done every 6 months to check my thyroid hormone levels and to check my blood pressure (I suffer from hypertension ). This is all the care I receive. My pain level most days (I have fibromyalgia) makes it impossible to function but I must suffer through it because there is no help for me. I am tired and my body is tired. I feel that complex care patients are being culled from health care and society.

Doc Anonymous

Perhaps the problem originated when the insurance companies were allowed to impose their model of medical care on the design of the ACA. The ramifications of the “business model” of medicine will probably have more adverse effects in years to come.

The exclusion of chronic pain patients from hospital owned practices goes back more than 20 years. Back in the mid 90s, I had a rapidly growing practice consisting of mostly injured workers with severe chronic back pain. I tried to get local hospitals to take over the business side of my practice in a time when hospitals were actively buying private practices for huge sums. I offered to do it if they would simply take on the business aspects and pay me a salary. There were 5 different hospital organizations then in my major metropolitan area. Not a single hospital wanted anything to do with a group of chronic back pain patients. The insurance industry had turned this group of patients into business losses for any physician who provided care. The hospitals saw my group of patients as a huge drain on resources, and therefore I stayed in solo practice……and yes I ended my career as a debtor while the hospital employees became at least moderately wealthy.

The Accountable Care Act as documented above has been designed to heighten the real perception that chronic pain patients are economic drains on the business.