Stanley Feld M.D.,FACP,MACE
It is going to be very difficult for physicians and hospital systems to develop integrated medical delivery systems in the present time frame.
Dr. Don Berwick and his associates have a naïve view of the ability of organizations to form and execute Accountable Care Organizations (ACOs). ACOs fit well into President Obama’s worldview of government controlling our healthcare system.
There are two problems:
- The government is broke. It does not have the money to pay for a government takeover of the healthcare system.
- New systems need participant cooperation to succeed.
President Obama and Dr. Don Berwick have overestimated the abilities of the healthcare system to respond to their hubristic assumptions.
“The ACO program is based on the hubristic assumption that the federal government can design the best organizational structure for the delivery of care, foster its development, and control its operation for the entire country."
Below are some of the defective assumptions made to implement ACOs.
Physicians and hospitals have little experience or control in managing risk. The experience with HMO’s in the 1980’s proved their inability to manage risk. Most physicians and hospital systems are not very interested in assuming this risk again. The risk of ACOs has been sugar coated by the administration.
Patients are the only stakeholders who can control their healthcare risk. All health policy wonks ignore the role of the patients in controlling and managing their healthcare risk.
Dr. Berwick thinks hospitals and physicians will be motivated to control patients’ healthcare risk with ACOs. He is wrong. I predict participation will be minimal. Those who participate in the ACO program will fail.
Healthcare policy should focus on how policy can provide incentives for patients to be motivated to control their own healthcare risk.
The implementation of electronic health records will be more challenging than President Obama and Dr. Berwick believe. The financial support from President Obama’s stimulus package is going to turn out to be a waste of money. The EMR’s cost more than the government subsidy.
EMR installation disrupts medical practices for at least six months. The incompatibility of information systems can only be overcome at great expense to both hospital and physician.
President Obama should be spending the stimulus money on the Ideal EMR. It would cost physicians and hospitals nothing. They would pay by the click. It would unify all the information systems nationwide. The Idea EMR would remove many of the barriers to achieving the goal of integrating medical data.
Data measurement imposes another difficult barrier to implementation of ACOs. I have wondered what date U.S. News and World Report used to name Parkland Memorial Hospital among the 100 best hospitals in the nation while Center for Medicare and Medicaid Services (CMS) used other data to disqualify Parkland Memorial Hospital from collecting Medicare and Medicaid reimbursement. I believe Parkland is a great hospital with a great CEO, Dr. Ron Anderson. Someone’s data is wrong.
Can physicians and hospital systems trust CMS to measure their performance and pay for performance based on the data used?
The challenge of collecting, analyzing, and reporting performance data will be the ACOs responsibility. CMS will evaluate the data collected and determine payment for performance.
Most ACOs will have difficulty developing the data and reporting capability with present EMR capabilities.
A goal of ACOs will be to implement standardized care management protocols. If successful it will commoditize medical practice. It will eliminate physicians’ judgment. It will destroy the patient-physician relationship.
I believe all physicians should practice evident based medicine (EBM). In the absence of tort reform physicians cannot avoid the practice of defensive medicine.
ACOs are not designed to align the stakeholders’ vested interests. I can visualize hospitals fighting with their physicians over money distribution and medical care decisions. Payments for medical care are going to be bundled. In order to save money and receive the shared saving bonus, patients may have medical care rationed.
ACOs are Primary Care Physician(PCP) centric. There is no requirement for specialists to limit their activity to a single ACO. Specialists will be critical to the effective performance of ACOs in order to qualify for the shared savings bonus.
Who will decide which specialist a PCP will refer patients to? There will be fights about fees to pay specialists. Obamacare’s ACOs make no attempt to align providers’ vested interests. It leaves it up to the providers. Since hospital administrators will control the money fighting is inevitable.
Patients must be the leader of the healthcare team. Obamacare and ACOs make no attempt to put patients in a responsible, leadership position. Patients and family members must participate in managing multiple, complex chronic conditions. Patients need to be taught to manage and take responsibility for their health and health care. They need to be taught to engage their family and have the family participate in medical decision-making.
Obamacare does not outline systems of care for chronic diseases for the potential ACO that might not have experience in team management.
ACOs may not have the necessary management and implementation skills required to improve care delivered to patients. Improvement in medical care will require team management of chronic disease. Patients must be the leader of their team. This will require aligning shared interests and rewards among the different providers. This is where physicians and hospitals will lock horns.
New regulations have to be coordinated with the Stark anti- kickback legislation. It will require costs that have nothing to do with direct patient care. Compliance with new regulatory requirements will require unprecedented and unmanageable levels of transparency and cooperation among hospital systems, physician organizations, and the payer.
There is too much emphasis on central data collection and managing the data. Much of medical management depends upon on the spot clinical judgment.
Learning systems must be built to have rapid cycle improvement in quality care. I suspect many physicians and hospital administrators do not know the importance of learning systems.
Developing cooperation among all the stakeholders to develop preventive medicine systems and systems of care for chronic disease does not develop overnight, especially when payment for those services are vague.
These are just a few of the defective assumptions made by President Obama and Dr. Don Berwick that will prevent ACOs’ success.