Massachusetts General Hospital

Harry E. Rubash, MD

Harry E. Rubash, M.D.

Edith M. Ashley Professor of Orthopaedic Surgery
Harvard Medical School

2012-13 Chief's Report

Accountable Care Organizations


In December 2011, the Center for Medicaid and Medicare Services (CMS) selected the Partners HealthCare system as a pioneer Accountable Care Organization (ACO). Boston is fertile ground for Pioneer ACO opportunities. At present there are four other Pioneer ACOs in eastern Massachusetts: Beth Israel Deaconess Medical Center, Mount Auburn Cambridge Independent Practice Association, Steward Health Care, and Atrius Health. This innovative, yet untested federal program is aimed at transforming the delivery of healthcare. The challenge is providing high-quality care while simultaneously slowing the growth of cost through a Care Coordination Program. We are now about 20 months into the program and more than 45,000 MGH patients were notified that their primary care physicians are participating in this new pilot.


With tremendous pressure on healthcare providers to reduce costs, it makes a great deal of sense for the MGH to get involved.


The Institution is investing in necessary infrastructure to better coordinate care for our patients. This work helps us prepare patients to negotiate and navigate our complex academic healthcare system.


We have made the needed investments in staff and equipment in order to be on the “gain” side of the equation as the government processes our ACO results. If the total annual cost for all ACO patients goes up faster than the cost of Medicare spending across the country, the Massachusetts General Physicians Organization (MGPO) and the Hospital, as a whole, will pay back the difference between these two benchmarks to the government. However, if there is a decrease in that spending (a “gain”), the monies will be shared at the Institutional level. In the first round, there are limits on how much an ACO can “gain” or “lose.” In addition, an MGPO physician’s compensation is not at risk in the first round.


As we have seen from past experience, payment models don’t ensure success – they only create an opportunity. Capitation failed and focused on population care with the primary care physician as a “gatekeeper.” Effective primary care will continue to be the key to the success of population management. An equally important issue will be the need to control the cost of each episode of care, and the referral of that care within our system. Thus, the process of care redesign – creating a more integrated, accessible and consistent approach to our specialty services – will win the day.


The efforts of the pioneer ACO are paralleled by a new series of risk contracts with our commercial insurers. While the risk pool for the three big payers is relatively modest at this point, the dollars at risk are substantial. Determined to avoid the mistakes of the past, the Institution is being careful to shield physicians from externally created cost and quality targets of risk sharing contracts. As a result, Partners has developed what is referred to as the Internal Performance Framework (IPF), which asks our physicians to focus only on the cost and quality targets we think make sense. In response, the Institution is investing in the infrastructure that will both help manage the cost as well as improve the quality of our patients’ care. This methodology was utilized successfully in the CMS demonstration. The program, which began in 2006, focused on better coordination of care for the sickest 15 percent of Medicare beneficiaries who account for over 75 percent of healthcare spending. This demonstration remains one of the only programs evaluated that actually reduced costs while improving patient care.


A number of smaller efforts – including patient portals, systems for documenting preventative services, and efforts to redesign care around particular diagnoses – have become an important part of our population management agenda. It is a great pleasure to work alongside Dr. Tim Ferris, who leads these initiatives across the MGH and Partners. His creativity and ingenuity have helped us navigate these difficult waters. Dr. Ferris has coordinated the top five tactics that can reduce cost and improve care: high-risk care management for patients with multiple conditions; virtual visit options for consultations; the use of decision aids to facilitate discussion between patients and providers; systematic review and documentation of procedures to ensure their appropriateness before they are performed; and, variance performance and reporting dashboards, which compare the fine work of our physicians to those of other institutions. Visit our orthopaedic website ( to see our initial attempts to provide some of this variance reporting across our services.

Next: Care Redesign >