by Robert Kornfeld, DPM, Board Member, AMS
The Independent Physician©
ACO’s (accountable care organizations) represent the newest
model in healthcare delivery. Its design is to make the physician “accountable”
for his diagnosis and treatment by reward and punishment. The thought behind
the advent of ACO’s (or what they’d
like us to believe) is to deliver HIGHER quality healthcare for fewer dollars.
This is supposedly accomplished with a capitation model. The belief that the
physician is more efficient in his approach to patient care if he is “in
charge” of the money is extremely flawed and over-simplistic. There are a
number of reasons why this is so.
Reason #1: There is a financial dis-incentive to quality care
What we have here is an absolutely
brilliant model if you are an insurance company. Healthcare expenditures are so
tightly controlled that the insurance company can maximize their bottom line
with much more accuracy. However, capitation models work best when minimal care
is provided.
If the physician spends less than the insurance company paid him, then the doctor is
rewarded with a higher profit. If the treatment plan costs more than what was
paid, then the doctor not only is not paid for his additional treatment,
he may be punished by owing the insurance carrier. Therefore, less is more; but,
in regards to patient care, it spells big trouble for quality outcomes.
Reason #2: Complex diagnoses may be ignored
In a payment model that depends
on less care, physicians may be loathe to diagnose and treat complex diseases
that require complex treatments. These needy patients represent a portion of
the population that will wind up costing the doctor time and money. Since
altruism does not pay the bills, it is quite possible that many patients will
fall through the cracks in this system and either be under-treated or
under-diagnosed. This is a dangerous
precedent to set in a society whose morbidity has been on the rise for decades.
Reason #3: We treat people, not diagnosis codes
In our modern medical billing
system, a diagnosis is made and identified by a diagnosis code. The doctor then
receives a capitated payment for that particular code. Since he/she is being
held to performance/expenditure targets, the ACO
will implement a treatment protocol designed to relieve the patient’s symptoms
quickly and inexpensively. However, human beings all exhibit unique responses
to treatment based on their own unique physiology and epigenetic tendencies. This basically
means that we are taking the “humanity” out of the treatment in the ACO model since we can no longer tolerate the patient with
co-morbidities whose response to treatment may not be ideal for profiteering.
So, the best treated patients may end up being those who present with a cold,
while a patient with diabetes, heart disease, arthritis or IBD may be left to
linger and suffer due to the costs involved in rendering adequate care. Our
ingrained, ‘mechanistic’ approach to patient care, where we, for instance, identify
a particular patient’s immune burden (to effect functional improvement in their
in their infectious or malignant physiology) will be too expensive for an ACO model. ACOs are designed to target
symptoms through rote protocols, rather than to pursue true healing regimens to
optimize patients’ health, safety, and well-being.
Reason #4: Minimizing costs means maximizing the ‘easy fix’ approach
Since the model for payment
depends on expedient care, there is an incentive to seek partial treatments of
patients, such as through the use of medicines without adequate workups or
follow-ups. This means that doctors will be reaching for their prescription
pads to reduce expenditures by writing a prescription to get the patient out of
the door quickly. Drugs can be marvelous
treatment options, but should always be accompanied by proper medical care and
attention. And as for prescription
medicines, ACOs will very carefully design their electronic IT ‘platforms’ so
that not all drugs are equally represented. When medication treatment is
advised, doctors may find that the most therapeutic drug is not on formulary or
not easily accessible via the ACO e-script software because it may cost more
than a less-effective alternative .
Reason #5: ACO’s undermine the doctor-patient relationship
The ACO model lets the insurance company off the hook and puts the doctor under
incredible stress to ‘perform’. Since the ACO payment model rewards doctors for
providing less care, the patient may now become the doctor’s very own adversary.
A patient with greater needs may feel abandoned by physicians whose time is not
well spent on their care. Thus, many patients will begin to feel a lack of
caring, lack of connection, and decreased confidence in the doctor and the health
system. The potential for patients to mistrust a health network that already has
a tendency to breed confusion and animosity–and, in many cases, contempt for
physicians–can spell disaster. Studies have shown that patients who have greater
confidence in their physicians heal much better than patients who don’t.
ACOs are simply ‘mini-HMOs’ with a new
government-sponsored mandate to further constrain doctors and limit the breadth
and scope of patient care. Those doctors and administrators who tout the
prospects for ACOs are most likely to be the very same ones who have positioned
themselves at the top of the health network food chain. These physicians look
toward stipends and payments schemes for sitting as ACO trustees and board
members. Some willfully disregard their fellow colleagues for
self-serving reasons.
Many feel that whole medical specialties,
such as anesthesiology for example, could be downgraded to that of ‘employee’ if
the Obamacare/ACO model is allowed to take roots. As anesthesia doctors are forced to take a proportionally smaller cut of the ‘bundled’ pie for services rendered in an ACO
model, anesthesiologists may lose their independent, central, and imperative role in the
perioperative equation.
At a recent meeting of the American Society of Anesthesiologists, it was rumored that
leaders of that organization have already engaged in backroom discussions with
the White House/Centers for Medicare and Medicaid Services to eliminate the unique ‘anesthesia time’ component of anesthesia billing. If this comes to pass, the delivery of anesthesia services
could very well become nothing more than another bundled and packaged ‘secondary’ service in a patient’s
surgical experience. The practice of medicine should never be bundled and packaged…
Healthcare reform should include mechanisms to save money and improve patient care. Accountable Care Organizations will fail miserably on both counts.
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Bill Gunderson 
