Accountable Care Organizations and the need to innovate

There is a lot of buzz over the creation of Accountable Care Organizations (ACOs) under the Patient Protection and Affordable Care Act (PPACA).

An ACO is a network of health care providers and hospitals that collaboratively manage patient care and prospective budgets. Perhaps the biggest draw of ACOs is the potential to create innovative ways to improve quality and decrease costs. To accomplish these goals, ACOs require the use of evidence-based medicine. Currently, supporters of ACOs have suggested financial incentives to encourage adoption of evidence-based best practices. Critics have derided the emphasis on best practices, calling it “cookbook” medicine because it hinders physician autonomy to make clinical decisions. As long as progress is being made, physicians can live with a decrease of autonomy. Just one small problem–financial incentives may impede medical progress by restricting innovation.

The vast majority of research has focused on financial incentives schemes (e.g., pay-for-performance (P4P) and evidence-based medicine) and its affect on cost, quality, and access of care. Unfortunately, no research has been conducted examining the affect of financial incentives on medical innovation. However, behavioral psychology and behavioral economics research can teach health care reformers a thing or two.In short, the behavioral sciences researchers have found that financial incentives (i.e., rewards and penalties) are not effective for completing complex task which require and critical thinking and creativity. Daniel Pink, author of the book Drive: The Surprising Truth About What Motivates Us, discussed the topic on NPR:

Human beings have a natural urge for autonomy. [...] There’s an Australian software company called Atlassian, and they do something once a quarter where they say to their software developers: You can work on anything you want, any way you want, with whomever you want, you just have to show the results to the rest of the company at the end of 24 hours. They call these things ‘FedEx days,’ because you have to deliver something overnight. That one day of intense autonomy has produced a whole array of software fixes, a whole array of ideas for new products, a whole array of upgrades for existing products.

Since then other companies have followed suit: Yahoo! has “Hack Days” and Abode has “JDI days.” These trends have been found in numerous other fields from education to sports. But perhaps these findings are not surprising to parents who do not monetarily reward their children for good grades, or anyone who has come up with a brilliant idea in the shower–extrinsic rewards and pressure to perform well do not breed creativity.

Medicine, of course, requires a great deal of critical thinking. And so, physicians are not immune to these effects. Instead of external rewards, intrinsic desire must be the base of what makes us be better doctors. It must be the code and accountability that makes practicing medicine a profession. And professionalism itself in entrenched in the principles of autonomy and a greater sense of purpose. Indeed, research shows that having a purpose behind one’s work leads to increased job performance.

Of course, there are a number of reasons to support evidence-based practices. It can be a force of good to inspire adherence to professional norms. Perhaps the best example is the change of the practice of anesthesiology in the 1980s. At the time, there were an egregious number of preventable errors committed by anesthesiologists. Through promotion of optimal standards of care, the American Society of Anesthesiologists improved outcomes. But even good intentions can have unintended negative consequences.

My concern is that payment tied to evidence-based medicine will decrease the impetus to innovate. What good is a “cookbook” medicine if you can’t update the recipes? Digression from standards of care could mean a loss of money, so there is not much incentive to deter from the status quo. Most importantly, innovation in medicine has the potential to positively affect the main measures of good health care: cost, quality, and access. And thus, measures to encourage and maintain innovation must be considered with the implementation of ACOs.

Kunmi Sobowale is a medical student.

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  • soloFP

    You can have a cookbook process for bonuses. For the last three years I have gotten bonuses for reporting A1C, LDL chol, Systolic BP, and Diastolic BP codes to Medicare on my diabetic patients. Since 70-80% of my patients who have T2DM and are over 65 are well controlled, I created a billing script that automatically fills out the fields with the push of a button for the T2DM visits. The quality reporting does not take into account neuropathy, retinalpathy, tobacco use, foot ulcers, etc. A positive aspect of the 2% bonus and reporting is that it makes me look closer at all of my T2DM for these qualities. A negative aspect would be if the uncontrolled diabetic patient caused a loss in income and office visit fees. Many practices would potentially discharge noncompliant and uncontrolled diabetic patients, if it meant a loss in income under P4P.

  • Brennan

    “What good is a “cookbook” medicine if you can’t update the recipes?”

    I would argue that the cookbook is constantly being updated by waves of new research/publications. It’s the physicians responsibility to keep up to date and interpret the literature correctly. Moreover, shouldn’t the innovators be designated to the behind the scenes researchers who produce updates to the “cookbook”?

    I don’t think this takes any autonomy from the physician. Nobody is forcing physicians how to interpret a particular evidence-based finding, or how to incorporate new “recipes” into treatment plans for their patients.

  • Christina Palmer

    This is an excellent article – thank you. I really appreciate how you applied those important behavioral science findings to medicine.

    I strongly believe we need to borrow this idea: have your medical students/physicians to work on anything you want, any way you want, with whomever you want… you just have to show the results to the rest of the medical community at the end of 24 hours.

    Brilliant. That could lead to some truly innovative thinking in medicine.

    (I think Google may do something similar: 1/2 a day a week employees are free to work on whatever they want… they certainly don’t seem to be lacking in innovation!).

  • Anthony

    Nice article Kunmi. Why aren’t you taking the QI elective with us? ;)

    I’ll have to disagree with you though. I don’t think the problem is a lack of innovation. We already know how to do many things well, we just don’t do them. If the Mayo Clinic can provide excellent care in the last two years of life for less than $30,000, why does it cost us ~$70,000 to do the same thing here at the UCMC? The knowledge of how to do it for $30,000 exists (Mayo), we just aren’t applying that knowledge at other places. Autonomy is no good if it means people are going to keep on doing things the same expensive and ineffective way they were before and not adopt best practices from across the country…or even worse, innovate new, more expensive technologies of questionable efficacy that drive costs even higher.

    Just my two cents. :)

  • Paulo Machado

    Nice piece and good comments.

    Like any Chef will tell you a cookbook points you in the right direction then can be personalized based on your goal.

    Doctors currently practice evidence based medicine. With HCR the goal is to use the best practices that get you the highest value (best health outcome at the lowest cost) on a much more consistent basis. The reward needs to be balanced properly between the outcome and the process. We are learning what that balance needs to be now…

    We need to keep our eye on the long term goal. No one ever said it would be easy to redesign the US Healthcare Nation.

  • C

    What came to mind when reading this piece is where the innovation can live in the phycisian’s practice.

    While the evidence based approach to treating a diabetic, e.g., is a nice recipe, getting the patient to follow the recipe is a different story; no two patients are alike in the approach to their care, nor are the life-barriers that impede progress (or the support systems that facilitate progress).

    Currently, a physician has no time, nor are they compensated, to be innovative in their approach to getting the patient to follow evidence based guidelines. Isn’t this the real reason healthcare exists – to treat the patient. Innovation can start at this micro level of care. Don’t you think?

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