Saturday, June 06, 2009

How do you make an ACO accountable?

A letter to the editor in the New York times from Timothy Ford follows up on a point I made the other day about the President's proposals for "accountable care organizations," an idea that is also getting a lot of talk in Massachusetts in the deliberations of the payment reform commission.

Here's the pertinent part:

What our system needs are more Kaiser, Geisinger, Mayo and Intermountain health systems. These are the integrated delivery systems that are already delivering higher quality and lower costs. But the Medicare and Medicaid programs have been no more successful than private insurers in supporting the growth of these organizations. If you want to see real health reform, we need to have incentives to encourage more of these entities to emerge.

Here in Massachusetts, there is only one such entity that approaches the definition of an ACO, Partners Healthcare System. But there is no sign that it has used its size and scale to deliver care at a lower cost. Indeed, there is evidence that it has used its market power to extract higher rates from insurance companies. Likewise, there are no data to show that quality, safety, and efficacy in the delivery of care throughout the Partners system is better than other community hospitals or academic medical centers.

It seems to be time to ask the question explicitly. Is it the desire of MA state officials that the rest of the hospitals become integrated systems? (As a side question, how many such systems do you want in the state?) If so, how would you hold them accountable? So far, there is little evidence of governmental ability or political will to do so. Who is creating the policy framework that considers this issue in a manner that goes beyond the structure of reimbursements?

While we are at it, who is looking at the issue of plan design? If you create ACOs, you probably intend to limit consumer choice of physicians and doctors as part of their insurance plans. Do you mean to put the primary care doctors in the middle of that issue, restoring them to the hated "gatekeeper" role we saw during the era of managed care?

Focusing solely on reimbursement models is a recipe for failure. Let's think more broadly.


Anonymous said...

I would think even more broadly than that, to a point where there is no longer health "insurance" in the sense that one normally conceives of insurance. I have tried to make the point many times on many blogs that the mindset of an insurance executive runs diametrically opposite to the lifetime health needs of a patient, since everyone needs health care. (E.g., one is not protecting against a rare/unexpected event as if your house burns down or you have a car accident.)
In addition, who says that a patient should be tied to ONE ACO for all his health care needs? Porter's book talks about organizations which have expertise in selected medical conditions, such as heart care or renal care. There is no health organization on earth that can be #1 in the country in all service lines. Do not compromise my ability as a patient to go to, say, the Cleveland Clinic for my mitral valve repair, when I know they have more expertise in that particular area than other heart centers. Similarly, pediatric soft tissue tumors are only expertly treated at a few centers nationwide.
Porter's book makes reference to replacing "insurance" companies with "patient advocate" companies, which assist the patient in finding the best care for his particular health need and assist with the financial arrangements. (I would have to refer to his book again for more $$ details.) It is the advocate/assistance mindset, rather than the insurance (minimize payors' risk at all costs) mindset that is needed.

Clearly there is much to be done. I fear that the debate has been sidetracked by the total preoccupation with "insurance."

nonlocal MD

Frank Opelka, MD FACS said...

Hi Paul,
Great blog site. ACOs are quite interesting. I think they have great value but let's remember that it took half a century or more to build the collaborations called for to make an ACO functional.

I believe ACOs can be built one service line at a time until the entire project is completed. The service line can take a longitudinal view of the patient - such as Geisinger's ProvenCare.

PCPs as gatekeepers is a proven failure. The ACOs who use this design will undoubtedly fail. A true ACO is far from the gatekeeper model. Instead see the PCP as ground zero for the top ten chronic conditions and as a place patients can go to find the best clinical pathway to efficiently guide them through the maze of appropriate care.

Always enjoy your blogs and John Halamka's site.

76 Degrees in San Diego said...

1. It should be
2. 3-4
3. Pay 4 Performance is a determines premium pricing
4. We see your raised hand and accept you!
5. Plan design is paralyzed by ERISA federal regulations....these regulations need modification to enable innovation
6. You have a choice:
a. primary care physicians use national guidelines in a sequential review process for authorizations for ascending services ( I wouldn't dismiss this yet)
b. severely limit the number of specialist appointments and procedural services and allow "open access"...(..."eh?")
c. charge substantially higher copayments for expensive services (see answer #5)

(time to "catch the wave")

Medic(three) said...

Great Blog Paul. I've added you to my blogroll.

I think that this debate is a worthy debate. The frustrating part for me is that while we discus the cost of healthcare all the time, we barely touch on quality.

My experience with Mayo clinics has not been good. The mass conglomerate approach leaves a bad taste in my mouth.

Wouldn't cutting back on CYA medicine prove to be much more cost effective?

Anonymous said...

Anonymous at 11:44 am said:
" . . . who says that a patient should be tied to ONE ACO for all his health care needs? . . .There is no health organization on earth that can be #1 in the country in all service lines. Do not compromise my ability as a patient to go to, say, the Cleveland Clinic for my mitral valve repair, when I know they have more expertise in that particular area than other heart centers. Similarly, pediatric soft tissue tumors are only expertly treated at a few centers nationwide."

It is a reality that there will be a great variation in health care quality and outcomes depending on access available to the patient. In other words, a lot of people will suffer more and die earlier if the management of the new health care system denies some patients access to the best care.

An educated and presistent consumer will go after the best care available. The "health care system" should not prevent the consumer from getting the best available care in circumstances where it matters.

Medic(three) said...

anon--Do we honestly expect that consumers are educated--especially when it comes to health care?

Anonymous said...

Medic(three) - Some of us are educated and can get educated about our own health and options when we have a medical issue.

My primary care physican was indifferent about increases in my PSA but set up an appointment when I pressed him. The ultrasound and biopsy resulted in a diagnosis of prostate CA.

The urologist (a) told me by phone and did not discuss alternatives and treatments (b) told me to pick up literature from his secretary, which was a book about living with advanced prostate cancer (c) made an appointmet for me with some doctor doing research on radiation implants.

I insisted on getting the pathology report, forwarded it to an oncologist who said that the pathology indicated that my best treatment would be prostatectomy. I found and consulted with a urologist/surgeon at a large outside-of-Boston clinic who removed the prostate. Six years later my Ultrasensitive PSA is not detectable (< 0.01).

The diagnosing urologist was not acting in my best interests and I found an alternative. When I have a health issue I want to be involved in decisions about my treatment. I don't want some "health care system" making final decisions that can affect my life.

76 Degrees in San Diego said...

Choice costs. More choice costs more.

W/R/T speed of is like driving in an east coast big city..."no sudden moves!"

W/R/T new insurance products....see how hard it is to modify ERISA

w/r/t existing products, this came from an insurance purchasing website:
"Point-of-Service Plan (POS)
The POS plan is like a combination of the HMO and PPO plans. You are required to designate an in-network physician to be your primary health care provider. You may go out-of-network if you choose, but in doing so, you will have to pay most of the cost yourself, unless a primary care physician refers you to that specific doctor. In that instance, the health plan will pay all or most of your bill. Depending on the networks available in your area, a POS plan may be a great choice for your small business, if your employees work in multiple cities with different groups of doctors and hospitals available to them."....this is not NEW...

now, back to seeing patients....
(did I tell you that our hospital system ending its primary care residency training program because it was "not in the mission"?)

Anonymous said...

Speaking of choice - I have a friend (referred to in my above comment) who needed open heart valve surgery in his 40's. He was fortuitously able to take advantage of his employer's health plan's annual open enrollment period to switch coverage from POS to PPO so that he could go to the Cleveland Clinic, which has known expertise in his case, which involved both mitral leaflets. The increase in premium was 15%, in contrast to the $20,000 he would have had to pay out of pocket under the POS out of network.

He has made an interesting point to me, in that he believes that his overall cost to his insurance company and employer was REDUCED by receiving the Clinic's well organized (even assembly line-like) and minimally invasive surgery - in shortened length of stay, efficiency of testing/costs, and reduced time off work.

This is an interesting idea. Perhaps we are not measuring all of the right things for "outcome".


seedexpert said...

Anonymous is quite right about not tying a patient to an ACO...prostate cancer being an excellent example. Some primary care physicians are nihilistic about prostate cancer and wouldn't even screen a patient, given that the US Preventive Services Task Force won't take a stand either for it or against it (screening). Clearly there is a role for centers or physicians of excellence which a patient should be able to pursue within the structure of his/her health insurance benefit package. I would point out though that Anonymous is incorrect in stating that radioactive seed implantation for prostate cancer--for properly selected patients--amounts to "research," when there is 15 year outcome data substantiating its efficacy.

Anonymous said...

Do I understand correctly that all Massachusetts physicians may be forced to join ACOs?


Wouldn't that be a gross violation of our constitutional rights?

Karen Corrigan said...

You raise important questions here. If we are simply creating "Managed Care Part II: The Sequel" we're likely to be disappointed in the outcome.

Karen Corrigan