Accountable Care Organizations to Replace Insurance Companies in US

by Dr. Simi Paknikar on Feb 1 2012 3:26 PM
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Insurance companies in the United States may soon become extinct, according to a blog posted on the Opinion Pages of the New York Times website.

Under the current health insurance system, employers or individuals pay a premium to an insurance company. The insurance company then covers the costs of treatments based on the claims presented by the patients.

The health insurance system has many drawbacks.  Insurance companies identify health issues before enrolling a person into a policy and exclude pre-existing diseases from the coverage.  This exclusion policy however will be banned in the US from 2014.  The premium amount depends on the health of the person.  In some cases, the insurance companies require prior authorization of tests conducted or any treatment given.  They also sometimes refuse to pay for covered services, forcing the patients to appeal, thus increasing the administrative burden on the patients as well as the doctors.

The authors of the blog predict that the health insurance system in the United States will be replaced by a new system consisting of accountable care organizations (ACOs).  These organizations will be made up of groups of doctors, hospitals and other health care providers, who will take care of all the health care needs of the patients.  This model will enable consumers to choose their primary provider and his/her team. 

The authors list out several advantages of the new health-care system.  The ACOs are likely to shift the focus from treating sick patients to keeping people healthy.  They will be paid a fixed amount on a per-patient basis rather than on a per visit or per-hospitalization basis, with bonuses on achieving quality targets.  Thus, they will earn better by ensuring that their patients remain healthy rather than be admitted to the hospital.

The payments to the ACOs will directly flow from the employers, Medicare or Medicaid.  Insurance companies will not be required to handle billing and claims.

The ACOs will probably be a boon to many patients who are at the mercy of insurance companies.  It remains to be seen if such changes in the health insurance systems will be seen in India as well.