How an ACO will affect the relationship between a doctor and a patient

At the heart of medicine is the relationship between a doctor and a patient.

The more a doctor knows about his patients, the better. While visual changes and numbness might represent migraine symptoms for one patient, for another they could forebode a stroke. Having followed patients through the stages of life, participating in their medical experiences firsthand rather than solely reviewing those as written case-files — I can vouch that knowing their lifestyle and personality helps doctors not only in diagnosis but also in tailoring treatment.

Somewhere along the line, we have lost sight of this. Today, very few patients have a relationship with a single doctor; conversely doctors may be losing the direct patient focus, as they, themselves have to deal with increasingly larger supervisory medical organizations: independent physician associations (IPAs), physician hospital organizations (PHOs), integrated delivery networks (IDNs), and soon the newest creation of the health-care system, accountable care organizations (ACOs).

ACOs would fundamentally change how Massachusetts healthcare providers are allowed to organize their businesses and how insurers will be limited in the insurance-product choices allowed to patients. Instead of accepting fee for service, these new large, integrated systems will be paid a predetermined amount for each patient under care. Medical providers would increasingly be asked to take on the role of insurance company. If they keep costs down, they will be rewarded, but if they exceed the budget, they will have to cover those excess costs out of their own pocket, actually paying to provide medical treatment. “Medical provider as sub-insurance entity, taking on financial risk”: I don’t recall that role from medical school or from the Hippocratic Oath.

Doctors, previously in compact with a patient together battling a disease, now will be held accountable for group-related “outcomes”. Rather than being rewarded for success in diagnosis, they may be punished falling short of metrics (as yet to be determined: by a state, a commission, or a consortium).

Will any given desirable outcome be permanent? Presume doctors succeed in organizing longevity, translating to greater nursing home fees. As those fees become their own burden, will doctors be pressured to pursue yet some other socially (not medically) determined outcome? Do people want government’s foot on the scale in the doctor’s office?

Transferring risk from insurer to provider is not altogether new. In the 90s, health maintenance organization (HMOs) tried a similar method called capitation. The system had its cost-benefit, but wasn’t across-the-board popular. Patients grew concerned that physicians were being paid to withhold care. They also wanted greater freedom to see specialists. Insurance companies responded, appropriately, creating different tiers of offerings, trading privilege for price, maintaining simultaneously HMO, PPO, and fee-for-service options.

The new ACOs (with their group-outcome risk-assumption by medical providers) figure to be HMO’s “on steroids” — in and of itself not necessarily a terrible idea; but quickly becoming just that — if existing insurance products, as competitive ballast, are eliminated by fiat: what is proposed by the state of Massachusetts, as we write.

ACOs will be law, enforced by government that essentially stipulates its superiority in judgment to the peoples’ (given the previous popular rejection of HMO’s). The state, nonetheless, will impose its rules and limitations on insurers, henceforth able only to provide one anointed insurance-product. There will be no other option.

ACOs encourage market-consolidation. Hospitals, positioning themselves to become integrated systems join forces: purchase some physician practices ignoring others; choose separate, non-conflicting geographical areas — spheres of influence, in a real-life version of the boardgame Risk. Crowding out the smaller hospitals and independent doctors will result in decreased competition and lessened innovation. These new larger entities, contrary to the stated designs of the ACO-plan, can use this greater leverage with insurance companies to drive health-care costs higher.

Community-based solo practices will likely be driven to extinction with the adoption of ACOs. In 25 years’ of practicing medicine (such as mine), doctors see parents’ infants grow to parents themselves, dependable adults gracefully age to more dependent seniors, while providing attentiveness and personalized care considering personalities, families, and community. Long-term primary care clinicians (PCC’s) tend to order fewer tests through more time in conversation, addressing not just the symptom, but the person’s reaction to it.

But even with this high level of care, smaller group PCC reimbursement rates are lower than institutions’ due to the latter’s leverage over insurers; yet if not in a financial position to become an insurance-entity, any smaller practice will founder and disappear.

Six years ago, I began treating people struggling with narcotic addiction. While many doctors use a replacement narcotic therapy with no end, I focus on removing patients’ dependency, arming them with the skills and values needed to maintain drug-free life. These patients — mostly on Medicare and Medicaid — approach a time in which they no longer require treatment for addiction, decreasing the financial burden on these state-benefit programs and the taxpayers. This ability to tailor a unique, gently tapering, few-month program emanates from the independence of a small practice, in an environment of choice, not dictates. Smaller practice size affords an ability to adapt to the needs of patients, creating this innovate approach, allowing people get on with their lives.

Drug users, a particularly needy population, present, as a very high-risk impediment for inclusion within an ACO. Drug users, hyper-utilizers of the medical system, periodically engender medical visits for detoxification, and in the meanwhile often manipulate multiple medical visits for secondary gain in pursuit of narcotic-prescriptions. Add in counseling, groups, X-rays and tests from injuries and diseases incurred from a drug-lifestyle, and “pretty soon you’re talking about real money” — money an ACO might desire to retain over these wayward patients’ business.

Such patients may suffer as small, nimble, free-thinking practices, like my own, no longer treat, in avoiding the financial burden coincident with their profligate medical usage. Doctors will be required to take on more risk, while these patients may not be asked to take on additional responsibility, themselves, for their care and “outcomes”. In fact, while receiving state-benefits, they are insulated from any understanding or absorption of the costs involved. Instead, they are offered endless and repetitive medical options at no cost instead of paying (even tolerable “cigarette-money” copayment-levels) for each individual service. People choose items differently at a buffet from à la carte, and arrive far more frequently when that buffet is free.

When we ask people to contribute, proportionally, to the costs involved for their medical treatment, e.g. $10 a sore-throat at the PCC versus $50 at an ENT, they make an adult choice. Under ACO, such choices will be restricted “by the system.”  People capable of making positive health decisions will be penalized with decreased health-care options while (likely) subsidizing the costs of those who are engaging in the riskier behaviors that result in the frequent and expensive use of the medical system.

Removing patients, as ACOs do, from the equation of fixing their own health issues infantilizes them. Patients (in the child-role) will be hectored into (what is deemed) proper medical testing and personal behaviors by the (financially-at-risk parental) medical establishment. This will naturally lead to tension and unintended consequences, fraying the doctor-patient relationship, diminishing doctors’ currently high moral-standing and respect within the community.

Instead of further divorcing patients from the financial risks involved with their health decisions, we should return to a state closer that which pertains in their other investment- and life-decisions. Medical savings accounts directly reward patients’ keeping health-care costs down, additionally (over the long run) incentivizing those more time-consuming decisions to lose excess weight, stop smoking, and the like once rewards are in place that bring their own health-care costs down. This is the direction we should be headed.

Consider as example, briefly, public housing. Tenants have no financial investment in the buildings, which quickly become rundown, littered, and covered with graffiti. Conditions improve when tenants become owners, their property-value on the line. They will work to increase the value of their property: they monitor, no longer ignore, the common areas. They invest in improving and maximally maintaining the building because there are rewarded, simply and financially, themselves.

ACOs will naturally lead to a rationing of care. “Who-gets-what” options for everything from the flu to cancer will be decided by regulations decided at a remove rather than by medical judgment at a visit. Medicine changes faster than bureaucrats’ issuances — so, even in the best scenario, any well-considered document will outlast its usefulness. ACOs discourage innovation, limit competition, decide medical-care- winners and -losers care, and usurp the popular will already shown to be wary of heavy-handed incursions on personal health choices. ACOs create a one-size-fits-all approach that will irritate patients, discourage innovation, infringe on business-rights across-the-board — with no guarantee of decreased prices, given decreased competition via consolidation within each physical catchment area.

In Massachusetts, it is already hard to find a primary care doctor. If ACOs are put into place, it will only get harder as these new layers of bureaucracy create obstacles to maintaining a successful practice. Doctors will vote with their feet. Massachusetts has fine medical schools and will provide fine doctors for the less restrictive states of the union. We need to foster communication and innovation, rather than drowning them in a sea of new guidelines and regulations. We need to encourage people to take responsibility for their own health. We need to get back to focusing on the doctor-patient relationship and making both parties more active in the process, not less.

Randall S. Bock is a primary care physician who blogs at Doctoring the Evidence.

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  • Tom Dahlborg

    Dear Dr. Bock,

    Great to see your perspective shared here.

    We were founded on relationship and continue to preach the importance of time, relationship, trust, authentic connection, empathy all in conjunction with cutting-edge medicine.

    Healing is optimized when a patient and practitioner have a real authentic relationship & connection & trust. (Which of course requires time).

    With this healing container of trust and relationship a patient is able and willing to confide and share nuggets of wisdom critical to positioning them to heal and that would never have been shared in a twelve minute office visit with rotating practitioners in care teams.

    I also have significant concerns with the ACO model which I had shared back in December at:

    So again thank you for sharing this important message.


  • Solomd

    *Community-based solo practices will likely be driven to extinction with the adoption of ACOs.*

    As a solo independent family physician, I still gotta think that there will be a demand for my services by those whom the ACO practices kick out and by those who think the wave of the future medicine is as much crap as I do.

  • pcp

    Dr. Bock:

    I don’t agree with everything you say, but appreciate your careful review of ACOs. This is exactly the type of well-considered analysis one would expect from the primary care societies. Instead, the AAFP gives us instructions on how to affiliate with ACOs. The word’s oldest profession is thriving.

  • soloFP

    The sickest and therefore most costly patients will be discharged from ACO practices, along with the noncompliant paitents, to show efficiency and high quality of care. Even have a low quality and poor health of your patients, you won’t get your bonus. This already is happening with capitated HMOs and capitated Medicare plans.

    • Solomd

      soloFP, I don’t know about you, but not everyone is planning on staying beneath Medicare’s iron fist. Someone else can have my “bonus”.

  • imdoc

    So, it sounds like as a patient, one is required to utilize the local district ACO. Your doctor is chosen for you and if you don’t like him/her, you have to move across town. Perception of quality by the recipient of the service is irrelevant as quality standards will be determined by higher powers. This is all paid for by forcible extraction of taxes or premiums – and of course, there will never be “enough money”, so continuous referendum efforts will be needed. Money will need to be siphoned from rich ACO’s to the poor ACO’s where it is harder to get revenues. Lots of lobbying will occur for special interests of various types to re-allocate funding. The only thing missing is a “provider union”, underfunded pensions, and a “No Patient Left Behind” program…well, and also free low quality meals provided by Dept of Ag.

  • Marc Gorayeb, MD

    All right! It’s time to make your voices heard. I am confident that the government model will ultimately fail, but not before causing a lot of unecessary expense, pain and dislocation. Just like Obamacare, it’s better to kill this beast before it begins to rampage through our lives.



    But we are still left with HITECH and EMTALA.

    I am with you but I am becoming despondent with the fight as I sit on my medical society executive committee meetings refusing to drink the coolaid that all the others at the table seemed to have partaken in.

    Well meaning docs that defend their position by the statement, “well it is the law of the land….”

    Most of the docs are employed and or academic. Our immediate past president makes his living in the medical insurance end of medicine and our current society president is the regional CMS representative. Both are docs and are good guys but I feel bring a tenor that may not be best aligned with the “antiquated” fee for service private practitioners’ interests.

    Where to turn?

  • Charles DAgostino MD

    The problem remains that ACOs don’t solve the problem. All they do is level out an inherently cyclical business with docs and hospitals left to deal with the ups and downs.

    Why will no one discuss a real solution?

    I don’t have all the answers but for starters we need to break down state barriers and let their be free competition. It worked for life insurance (the internet caused a dramatic drop in cost) so why not try it. What’s to lose? It can be done quickly and at little to no cost.

    And I want real numbers. How effective has tiered pharmaceutical use and prior authorizations saved? All we hear is that it’s not enough. Then why are we doing it?

  • Paul Dorio

    Excellent commentary. Thanks.

    “Patients grew concerned that physicians were being paid to withhold care.”

    With ACOs they’ve gone one better: Now doctors won’t be paid to withhold care, OR to provide care. Bundled payments would eliminate that association and decrease what ALL providers get paid.

    Why it is too opaque for regulators to see how patient care will absolutely suffer under bundled payments is far beyond my level of understanding.

    The issue in our broken healthcare system is obvious: Insurers and the federal government run the show. The federal gov sets prices, a la Medicare, while the insurers dole out payments like Methadone to heroin addicts. How do we get our fix? Only by playing their game their way. I’m getting tired of the game and I’m only 40!

  • Joe Heyman

    When an organization is “accountable”, nobody is accountable. With capitation there is a culture of denial of care developed. If it is true that fee-for-service incents “doing too much”, then it also is true that capitation incents doing too little. As a patient, I want my doctor to take care of me doing whatever she feels is best without worrying about how it might affect her pocketbook.
    This coming episode of capitation will end up with the same public pushback as with HMOs. The difference this time is that instead of blaming insurers, they will blame us!

  • John Kaegi

    Wow, ACOs will spell the end of the world. While I agree with your premise that people should be held accountable for their health, I don’t agree that ACOs will diminish the patient-doctor relationship — with the right incentives (and disincentives, as you spell out), ACOs will be contemporary practices that are focused on holistic health rather than episodic, symptomatic acute care “drive-throughs.” And how did doctors get into this? The same way insurers got into trouble. In the HMO era, they did indeed withhold care to manage costs. Similarly, doctors in general withhold wellness attention to manage costs, thereby dramatically increasing health care costs due to uncontrolled, epidemic chronic illness. If our medical community focused on keeping people healthy rather than just fixing immediate symptoms, we wouldn’t be in this fix. Thank the almighty FFS reimbursement methodology for that.

    • Paul Dorio

      You said: “With the right incentives,…ACOs will be contemporary practices that are focused on holistic health rather than episodic, symptomatic acute care “drive-throughs.””

      With respect, that may be a lofty and idealistic goal, but it can never be achieved. Holistic health is not even in most people’s lexicons, let alone desires. Health in such manner begins at home, individually, and without doctor input. In order to “heal the whole person” and not the disease, one must have the cooperation of the individual – better eating habits; better health maintenance through increased activity levels; decreased vices such as smoking and moderation of alcohol intake. Once such habits are mandated by an Orwellian government (tongue-in-cheek now), then perhaps one could hope to successfully mandate the actions of doctors and base their pay on whether a person is successfully treated in such manner.

      (Sorry for a bit of a ramble there.)

    • imdoc

      Traditionally, a doctor is accountable only to the patient, not external entities. ACO means the patient’s care occurs with attention to budgets and globalized goals. This is just another stop along the way of de-professionalizing the whole thing. If the care you desire doesn’t fit the goals, I think you are naive to think you will get it.

  • John Kaegi

    Not long winded at all, and very insightful. I believe, however, that people WILL engage and change their behaviors through a combination of sticks (loss aversion) and carrots (incentives) and focused coaching (Dee Eddington stuff) in a trusting relationship with a practitioner. So, do I think the doctor can do all that? Absolutely not. But a doctor with a NP and a coach can. And that’s what it is going to take to reverse the epidemic health misbehavior in America today. Thanks.

  • gzuckier

    My take on it is, that we seem to be too much push, not enough pull, as it were. I know that in some of the European systems, rather than scale payment according to outcomes, they scale payment by difficulty of the case/patient. (Or maybe both?). This would seem to eliminate the problem of cherry picking easy patients to improve outcomes, as has proved over and over to be the easiest way to improve profitability in such circumstances.

    But then I wonder; I assume the bigwigs making the plans must know this stuff at least as well as I do, right? What’s the downside I don’t see?

    • Paul Dorio

      “Big wigs” “know this stuff” ????

      In my experience, reimbursements for a given procedure or test are across the board the same. They don’t adjust for a difficult PICC line, IVC filter placement, or CT scan. There isn’t any sliding scale of any sort.

      There should be.

  • Charles D’Agostino

    In response to gzuckier. I agree with the first part of your push pull analogy. At this point in history it’s the last chance we have to make a living, i.e. see easier patients since reimbursement keeps dropping in relation to overhead.

    As for getting extra money for difficult patients under a European model “Forget about it.” The goal in the US seems to be a salaried model like Europe. Instead of push and pull you will get “float.” A more diffiuclt patient means you float a little longer. I suspect most patients will become more difficult under this model.

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