Accountable care organizations: The lost art of medicine?

by Sharolyn Rhees Medina, MD

It’s no secret that healthcare’s inevitable move toward accountable care organizations (ACOs) has many physicians feeling a bit …nervous. Admittedly, most physicians are creatures of habit who fiercely defend their individual approach to patient care, focus on cures not cost, and dread the concept of “cookbook medicine.”

And under the ACO model, physicians are going to, without a doubt, be expected to move out of their comfort zones. But while ACOs will put new pressures on physicians to observe and adhere to evidence-based best practices, they will also allow physicians to preserve and deeply embrace the “art of medicine,” as well as enhance physicians’ skills and help improve outcomes by enabling them to spend more quality time with patients.

Our current healthcare system isn’t designed to encourage physicians to take a course of action that’s economically effective – especially since physicians are reimbursed by the service, regardless of the time spent and inefficiency it causes. The application of evidence-based best practices within ACOs will play a critical role in not only improving the economic system of healthcare, but the quality of patient care by making physicians accountable for outcomes and giving them the proven guidelines to help them do so. Physicians who practice good medicine – guided by best practices, but still driven by their own science – will see the reimbursements follow. This will cause a fundamental shift where physicians will be paid by the quality of their work, not the quantity of it.

In actuality, this model will give them the freedom to more deeply embrace the art of medicine and spend more time with patients – so it’s not just about money. It’s about making the physician’s job easier so they can focus on the more complicated and “heavy lifting” part of patient care. Yes, shaving half a day off ICU stays can result in significant savings over time, while reducing the number of blood tests required for a diabetic might not save a ton of money. However, fewer blood tests reduce the time physicians have to spend evaluating repetitive results, which means they can shift their attention to the patient and patient care.

Inpatient settings – which have a high-volume of patient visits and are swimming in a sea of valuable raw data (vital signs, lab results, etc.) – will likely see the biggest changes from the ACO model. In a ACO, all of this data can be converted into actionable intelligence that can quickly expose an abundance of inefficiencies that will ultimately help shift physicians’ mindsets from quantity to quality and enable them to focus on what they do best: the art of medicine.

Sharolyn Rhees Medina is an emergency medicine physician.

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  • Josh

    If you believe this, i have a bridge i’d like to sell you…

  • Steven Reznick MD

    I h.aven’t seen any evidence that ACO models are going to allow practitioners to spend more time with patients. The models I have seen discussed involve a team concept in which physician team members are more administrative coordinators working with data accumulated by the rest of the team. Much of the actual history taking and exam sessions are set up for nurses , nurse practitioners and physician assistants with the team physician acting much like an attending at a university center on teaching rounds. How much actual hands on face to face contact that physician has with patients remains to be seen.
    Evidence based medicine is a gathering of data on treatments that work. There are usually several options available for a given problem. It will take the art and science to apply the correct options to the correct situation. That is not “cookbook ” medicine.
    There will be great pressure on members of the ACO to be profitable. How that is achieved will be a major factor in whether the care is any better or worse than the current dysfunctional system

  • pcp

    ” this model will give them the freedom to more deeply embrace the art of medicine and spend more time with patients – so it’s not just about money. It’s about making the physician’s job easier so they can focus on the more complicated and “heavy lifting” part of patient care.”

    Pretty broad statements. Do you have ANY evidence to support your claims?

    As I said elsewhere:

    ACO = HMO + EMR

    • jsmith

      Of course there is no evidence. ACOs are simply the latest pie-in-the-sky panacea that will come to nothing but will enrich some players who make money on the deals. Health care is a big dumb lumbering industry. Sharks can grab a bite here and there. I like your equation, by the way, and fully intend to steal it.

      • pcp

        Thanks. I’ll have my lawyer contact you to sign a payment of royalties agreement.

        The point is that, in the wonderful world of ACOs, EMRs will be used to make all the features that everyone (docs and patients) hated about HMOs even more onerous.

        • Josh

          is it wrong to put a shameless plug in for affordable retainer medicine like my clinic,, $10-100/mo for unlimited visits (home/work/office/email/phone/sms/sm), wholesale meds/labs/supplies, free ekg, xray, dexa, bx, laceration repair…

          we’re actually working w/ ins to save people thousands (over our membership costs) off their current major medical/HSA plans…

          fresh out of residency, practice is open 6 months, 200 patients and growing (too quickly)…

          No ACO for me thank you very much.

  • Josh

    I’ll be seeing a patient today that i suspect has painful bladder syndrome / interstitial cystitis. Per “There is no good evidence showing that one treatment regimen is clearly superior to another.”

    I’m curious how the ACO is going to “help me” practice EBM when there’s no EBM….

    That bridge is still for sell if there are any takers out there.

  • Andy Yang

    There is nothing new in ACO. We were doing this 25 years ago in our HMO called MultiMed in Oklahoma City. We developed shared rick capitation system among PCPs, Specialists and hospitals. It worked very well.

  • BobBapaso

    Just another way to avoid the issue, and keep third parties in business. The only way costs will be lowered is when people pay for their care out of their own pockets, or Health Care Savings Accounts.

  • Josh

    Bob, people pay out of pocket at my clinic but at least they get the value of wholesale medications and labs and you know what, they usually chose the more affordable option.

    CMP $4
    CBC $2
    Lipid Panel $3
    Thyroid $4
    A1C $6

    Meds for 50-95% namebrand and wholesale prices..

    thats how you lower the cost of healthcare :)

  • Mark

    Andy and Josh…

    Andy- Exactly. No real change here except that the EMR approach allows an organization to report quality metrics and compliance with EBM automatically. And despite what someone commented, there’s about 20 things that are rooted in the evidence and do decrease costs. Lower A1C and keep blood pressure under control, and you are going to do better as a patient. I don’t think there’s a lot of disagreement there, but there’s a whole lot of people not doing it. There’s not good evidence for everything we do, but there was enough to start with 25 years ago, and we have made surprisingly little progress since.

    Josh. Why is your model not accountable? Your care is less expensive, but the patient also gets no assurance that they are getting the best care. That works when there is not any competition, but when someone comes into town with slightly higher prices, but is willing to put some of that price at risk to better outcomes, you have an ACO practice, and they will get the better, more compliant patients. And the ones they fire for not sticking to their health incentives will be in your office. This is a movie that’s being played out in my area right now.

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