Here is a short update on a post I put up about a month ago about CMS' proposed regulations for setting up Accountable Care Organizations. The ACO proposal calls for shared savings and other incentives for providers, with a transition after a few years to a real risk contract. But Congress put a "poison pill" into the concept because it was afraid to limit customer choice. At the heart of my argument was this point: "How can you be held accountable, as a provider group, if you cannot control the management of care of your patients?"
The latest news, according to my sources, is that even the most advanced ACO-like organizations like Geisinger and Mayo are not interested in signing on to this proposition. The financial risks can come crashing down quickly and are just too great.
In a recent Boston Globe interview, consultant Marc Bard explains how it would have to work for providers to agree to share risk in an ACO network:
Q. Some consumers fear they won’t be able to go to the doctors or specialists they want in the new system. Is that a legitimate fear?
A. The answer is of course. We can’t be spending 17.5 percent of our gross national product on health care and allow everybody to broker his or her own health care. So ultimately there are going to have to be trade-offs made. The public’s going to have to make them. The delivery systems are going to have to make them. Absolutely there are going to be limitations.
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Right on!!! I've been raising that concern often-- often getting irritated looks in return. Needs to be addressed in "framing" discussions. Where is the "accountable" component if this is part of the "rules?"
We already have narrow or limited network insurance products that place some restrictions on patients’ choice of providers in exchange for a lower insurance premium. Tiered networks, in effect, limit choices by charging higher co-payments to access more expensive doctors, hospitals, imaging centers and labs. Both products are gaining increasing traction with employers who are struggling to rein in the growth of healthcare costs.
ACO’s are just another variation on this theme. They can’t work without limiting patients’ choice of providers to an ACO approved limited or narrow network. I also think a key part of the equation will be for doctors, especially referring doctors, to make it part of their job to know and care about costs and quality when they make their referral decisions. They will need robust, user friendly transparency tools to help them. If I were running an ACO, I would tell them we need you to do this, we’re going to track the cost of the utilization driven by your referral decisions and, if you help us save money without withholding necessary care, we’re going to pay you more. For the best performers, we’ll pay you a lot more than you could expect to earn in the past. We will probably also need good, interoperable electronic medical records to allow for collecting and analyzing the data needed to evaluate the performance metrics that will determine bonus compensation.
I don't think that healthcare is going down either road of highly limiting providers (unless you are old or poor), or embracing patients as partners in care (especially if you are old or poor). Insurers have long limited networks, with little consequence among those yelling loudest about choice.
The fluidity of the working-age US population limits the ability to translate risk management into real continuity of care. Profound changes in technologies to capture and tame disparate sources of information - mostly electronic - about each individual, from your mortgage to your grocery habits - are available to comingle with the remote transfer blood pressure monitor you just installed by your bedside. A pleasant recorded voice will call to let you know that your glucose reading was a little high this morning, and a human might call if it is still high next week.
Provider choice will not be the ticket to contain costs, although providers would be the beneficiaries. Cloud technologies will allow any healthcare organization to pull data into proprietary algorithms. We'll call it "individualized medicine", and make you feel really good about it. But the poison is that you do not have the right to determine what data about you is being used, how it is weighted, and why you are sent to the specialist, and someone else is sent to a social worker.
John Toussaint blogged recently about Everett Clinic saying no to ACO's:
http://www.createhealthcarevalue.com/blog/post/?bid=230
Comment from The Health Care Blog:
I knew people didn’t like the language. Hadn’t realized it was bad enough that even Geisinger and Mayo won’t sign on.
Looks like employers are going to have to take the lead on this, as the politicians aren’t willing to get out in front of the pack and are still trying to be everything to everybody (without actually promising anything that will work).
The challenge, as always will be adding risk-taking capabilities to provider organizations in a way that can be administered by large employers nationally (ASO subset).
Since the leading ACO-like players are all regional entities, do you have a sense of who is capable of stepping into the gap?
Kaiser would seem to have the ability, but it never seems to have the will to make the most of its position. Who else has the balance sheet to absorb risk and the geographic span (with sufficient ability to improve the quality within network health providers) to make any of this happen?
I'm terrified that we'll be forced into an ACO. We've already experienced the nightmare of doctors being unwilling to refer outside of their own little network, despite knowing that for certain serious conditions the only appropriate care lies outside of that network. My wife and I are both living productive lives now only because we had enough money to be able to go outside the HMO that we were stuck in a few years ago when serious medical problems arose for each of us.
George Halvorson told me in an interview for an ACO project we just published that Kaiser will stick with Medicare Advantage.
Here's the HealthLeaders report link. Leaders Respond to CMS’ Proposed ACO Regulations
http://bit.ly/kpLtKx
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