The future of primary care in Accountable Care Organizations

A recent blog post in Health Affairs proclaimed The End of Internal Medicine As We Know It.  What the article is really asking is the future of primary care in the world of health care reform and the creation of Accountable Care Organizations (ACOs).

While doctors should be naturally concerned about change, I don’t completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient’s or employer’s health insurance premium, something that is sorely lacking in the current health care structure.  These were recently created and defined in the health care reform bill.

Yet, the author seems to suggest that this is a step backwards, writing, “modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions.”

Not true.  Successful organizations are ones that are tightly integrated – Apple, Fedex, Wal-mart, Disney.

The author talks briefly about how Europe in general does better than the US in terms of outcomes and costs and has a decentralized system.  All true.  However, contrasting Europe and America isn’t relevant.  After all, who isn’t still using the metric system?  Therefore solutions found outside the US probably aren’t applicable due to a variety of reasons.  Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago, like labeling primary care doctors (internists and family physicians) as “gatekeepers” rather than what we really do, never happens.

I love primary care.  I’ve worked at Kaiser Permanente (KP) in Northern California since 2000.  I have long term relationships with my patients.  They see me when they are well.   They see me when they are sick.  They have me as their personal doctor.  There are no mid-level practitioners (nurse practitioners or physician assistants) in my unit.  I’m supported by information technology, staff to help those members with chronic conditions, and collegial specialist colleagues.

In other words, I’m doing what almost every primary care doctor wants: long-term meaningful relationships with patients, no hassles from insurance companies, the ability to retrieve information quickly and easily, and support for specialty colleagues who are equally focused on the well-being of the patient and who respect me as much as I respect them.

Perhaps the death of primary care as it currently exists with crushing administrative hassles, loss of work-life balance, increasingly short office visits, and paper charts which often has inadequate information or are unavailable isn’t a bad idea after all.

Now I understand that KP looks very much like an ACO.   I also know it isn’t for everyone, doctors or patients, and isn’t the only solution for the country.  Certainly doctors should be wary of if every self-proclaimed “ACO” is really that or more of the same in the fee for service world but simply disguised in the ACO term.

However, for primary care doctors looking for a better way to care for patients, it is a very viable and sustainable solution.  If the future for primary care looks like what I see and do everyday, then I believe the future will be bright.

Patients in the end may benefit from ACOs.  I know my patients do.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • Cindy

    Funny, that’s not how KP works in our southern city. We have to see the nurse practioner over and over and over again before we get to see a doctor.

    • Leo Holm MD

      Google “Kaiser Permanente complaints” and prepare for an avalanche. The ACO is just a repackaged and rebranded version of capitation and rationing.

    • Davis Liu, MD

      I can only speak about Kaiser Permanente in Northern California. Your experience may be different outside of our region.

  • Steven Reznick MD

    Does your unit care for your patients when they are hospitalized or is the care transferred to another unit? If your patients are transferred to a local SNF for post injury or hospital rehab do you and your unit follow them or do they get turned over to other care providers? Do you make home visits?
    I am not trying to reduce or demean the valuable care and concern you provide to your patients as an employee of a large established and reknowned institution. I just believe that in other areas of the country, the greed of the parent institution and many of the procedure oriented practitioners will prevent primary care physicians from having a similar role.

    • Davis Liu, MD

      As I note in the article, I believe doctors need to be careful and thoughtful if joining an ACO as they are not all the same as you point out. The Permanente Medical Group, which is independent, physician led, and physician run, is one of the largest in the country.
      Only when the medical group is partnered with Kaiser Foundation Hospitals and Health Plan does the entity Kaiser Permanente exist.
      Should my patients need care in the hospital or rehabilitation in a skilled nursing facility, one of my colleagues in hospital medicine or elder care, will care for my patient until they are safe to go home. They have access to the same electronic medical record and can call me anytime if questions to make the hand-offs and transfers seamless.

  • tpouw

    ACO concept is not the problem. Who gets to run and own the organization is the crucial question. If it is run by for-profit, corporate-style insurance industry or hospital-owning corporation, then you will have bottom-line profit as the main driving force. Everything else will be window dressing!

  • Anonymous

    Primary care physicians must become the tomorrow’s physician executives. They will become, to a much greater degree patient medical quarterbacks, directing all aspects of care in their own practices and to specialists. From a payor’s perspective, primary care docs will manage/ coordinate employer wellness, DM and critical care efforts. They will be richly rewarded for cost and quality outcomes.

    From a population aspect, this move to unfragmented lower cost higher quality, must come from workplace provided/sponsored health benefits. As seen with the recent debt agreement, politicians by their very nature, are incapable of making decisions for the good of patients. Physicians must negoiate directly with employer plan sponsors. The MCOs are selling patients and providers, down-the-river! Everyone needs to pay close attention to the MCO/Obama Adm agreements to share MCO revenue in the exchange setting.

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