Accountable Care Organizations: "Accountable to Whom"

At the heart of medicine is the relationship between a doctor and a patient. The more a doctor knows about his patients, the better. For instance, vision-changes with numbness might represent migraine in one patient, and stroke in another. Having followed patients through the stages of life, participating in their medical experiences firsthand rather than solely reviewing those as written case-files -- I can vouch that knowing a patient's personality, habits, and proclivities helps not only in diagnosis but in tailoring treatment as well.

Somewhere along the line, we have lost sight of this. Today, few patients have the opportunity to continue a relationship with a single doctor; conversely doctors may be losing the direct patient focus, as they deal with increasingly larger supervisory medical organizations:

• independent physician associations (IPAs),
• physician hospital organizations (PHOs),
• integrated delivery networks (IDNs),
• and soon the newest creation of the health-care system, accountable care organizations (ACOs).

ACOs will fundamentally change Massachusetts health-care providers' ability to organize their own businesses and will limit insurers' product-choices available to consumers. Instead of accepting fee-for-service, these new large, integrated systems will receive a predetermined compensation-amount for each patient under care. Medical providers would increasingly be asked to take on the role of insurance company: rewarded if they keep patient-care costs down, and put at financial risk if they exceed budget, having to cover excess costs out of their own pocket. Doctors could find themselves paying rather than being paid to provide medical treatment. Medical school curricula should start including “Medical provider as sub-insurance entity, taking on financial risk”. As focus diverges from consideration of patient health above all to financial concerns overall, the Hippocratic Oath could yield to the Hypocritical Oath.

Doctors, previously in compact with a patient together battling a disease, now will be held accountable for group-related “outcomes”. Rather than being rewarded for success in diagnosis, they may be punished falling short of metrics (as yet to be determined: by a state, a commission, or a consortium).

Will any given desirable outcome be permanent? Presume doctors succeed in organizing longevity, translating to greater nursing home fees. As those fees become their own burden, will doctors be pressured to pursue yet some other socially (not medically) determined outcome? Do people want government’s foot on the scale in the doctor’s office?

Transferring risk from insurer to provider is not altogether new. In the 90s, health maintenance organization (HMOs) tried a similar method called capitation. The system had its cost-benefit, but wasn’t across-the-board popular. Patients grew concerned that physicians were being paid to withhold care. They also wanted greater freedom to see specialists. Insurance companies responded, appropriately, creating different tiers of offerings, trading privilege for price, maintaining simultaneously HMO, PPO, and fee-for-service options.

The new ACOs (with their group-outcome risk-assumption by medical providers) figure to be HMO’s “on steroids”--in and of itself not necessarily a terrible idea; but quickly becoming just that -- if existing insurance products, as competitive ballast, are eliminated by fiat: what is proposed by the state of Massachusetts, as we write.

ACOs will be law, enforced by government that essentially stipulates its superiority in judgment to the peoples’ (given the previous popular rejection of HMO’s). The state, nonetheless, will impose its rules and limitations on insurers, henceforth able only to provide one anointed insurance-product. There will be no other option.

ACOs encourage market-consolidation. Hospitals, positioning themselves to become integrated systems join forces: purchase some physician practices ignoring others; choose separate, non-conflicting geographical areas -- spheres of influence, in a real-life version of the boardgame Risk. Crowding out the smaller hospitals and independent doctors will result in decreased competition and lessened innovation. These new larger entities, contrary to the stated designs of the ACO-plan, can use this greater leverage with insurance companies to drive health-care costs higher.

Community-based solo practices will likely be driven to extinction with the adoption of ACOs. In 25 years’ of practicing medicine (such as mine), doctors see parents' infants grow to parents themselves, dependable adults gracefully age to more dependent seniors, while providing attentiveness and personalized care considering personalities, families, and community. Long-term primary care clinicians (PCC's) tend to order fewer tests through more time in conversation, addressing not just the symptom, but the person’s reaction to it.

But even with this high level of care, smaller group PCC reimbursement rates are lower than institutions’ due to the latter's leverage over insurers; yet if not in a financial position to become an insurance-entity, any smaller practice will founder and disappear.

Six years ago, I began treating people struggling with narcotic-addiction. While many doctors use a replacement-narcotic therapy with no end, I focus on removing patients’ dependency, arming them with the skills and values needed to maintain drug-free life. These patients -- mostly on Medicare and Medicaid -- approach a time in which they no longer require treatment for addiction, decreasing the financial burden on these state-benefit programs and the taxpayers. This ability to tailor a unique, gently tapering, few-month program emanates from the independence of a small practice, in an environment of choice, not dictates. Smaller practice size affords an ability to adapt to the needs of patients, creating this innovate approach, allowing people get on with their lives.

Drug-users, a particularly needy population, present, as a very high-risk impediment for inclusion within an ACO. Drug users, hyper-utilizers of the medical system, periodically engender medical visits for detoxification, and in the meanwhile often manipulate multiple medical visits for secondary gain in pursuit of narcotic-prescriptions. Add in counseling, groups, x-rays and tests from injuries and diseases incurred from a drug-lifestyle, and “pretty soon you’re talking about real money” -- money an ACO might desire to retain over these wayward patients’ business.

Such patients may suffer as small, nimble, free-thinking practices, like my own, no longer are open to treat, avoiding the financial burden coincident with their profligate medical usage. Doctors will be required to take on more risk, while these patients may not be asked to take on additional responsibility, themselves, for their care and "outcomes". In fact, while receiving state-benefits, they are insulated from any understanding or absorption of the costs involved. Instead, they are offered endless and repetitive medical options at no cost instead of paying (even tolerable “cigarette-money” copayment-levels) for each individual service. People choose items differently at a buffet from à la carte, and arrive far more frequently when that buffet is free.

When we ask people to contribute, proportionally, to the costs involved for their medical treatment, e.g. $10 a sore-throat at the PCC versus $50 at an ENT, they make an adult choice. Under ACO, such choices will be restricted “by the system”. People capable of making positive health decisions will be penalized with decreased health-care options while (likely) subsidizing the costs of those who are engaging in the riskier behaviors that result in the frequent and expensive use of the medical system.

Removing patients, as ACOs do, from the equation of fixing their own health issues infantilizes them. Patients (in the child-role) will be hectored into (what is deemed) proper medical testing and personal behaviors by the (financially-at-risk parental) medical establishment. This will naturally lead to tension and unintended consequences, fraying the doctor-patient relationship, diminishing doctors’ currently high moral-standing and respect within the community.

Instead of further divorcing patients from the financial risks involved with their health decisions, we should return to a state closer that which pertains in their other investment- and life-decisions. Medical savings accounts directly reward patients’ keeping health-care costs down, additionally (over the long run) incentivizing those more time-consuming decisions to lose excess weight, stop smoking, and the like once rewards are in place that bring their own health-care costs down. This is the direction in which we should be headed.

Consider as example, briefly, public housing. Tenants have no financial investment in the buildings, which quickly become rundown, littered, and covered with graffiti. Conditions improve when tenants become owners, their property-value on the line. They will work to increase the value of their property: they monitor, no longer ignore, the common areas. They invest in improving and maximally maintaining the building because they are rewarded, simply and financially, themselves.

ACOs will naturally lead to a rationing of care. “Who-gets-what” options for everything from the flu to cancer will be decided by regulations decided, at a remove -- rather than by medical judgment, at a visit. Medicine changes faster than bureaucrats’ issuances -- so, even in the best scenario, any well-considered document outlasts its usefulness. ACOs discourage innovation, limit competition, decide medical-care- winners and -losers care, and usurp the popular will already shown to be wary of heavy-handed incursions on personal health choices. ACOs create a one-size-fits-all approach that will irritate patients, discourage innovation, infringe on business-rights across-the-board -- with no guarantee of decreased prices, given decreased competition via consolidation within each physical catchment area.

In Massachusetts, it is already hard to find a primary care doctor. If ACOs are put into place, this process will only get harder as these new layers of bureaucracy create obstacles to maintaining a successful practice. Doctors will vote with their feet. Massachusetts' fine medical schools will send doctors increasingly to less restrictive states of the union.

• We need to foster communication and innovation, rather than drowning them in a sea of new guidelines and regulations.
• We need to encourage people to take responsibility for their own health.
• We need to get back to focusing on the doctor-patient relationship and making both parties more active in the process, not less.