ACOs and the modern day leper

In the Chicago Tribune recently, Bruce Japsen has an excellent article addressing Accountable Care Organizations, quality of care issues, and the change in how physicians will be paid in the future.

Clearly, the government and insurers have decided that physicians will not be paid for services rendered.  Physicians will be paid based on patient outcomes and will share in any losses insurers sustain due to poor patient outcomes.  There are going to be quality indicators and physicians with high quality scores will be paid more than those with low scores.

Are you a “leper”? Are you overweight, out of shape, or arthritic?  Do you smoke, drink alcohol, or do drugs?  Do you have any chronic medical problems?  Are you old, have poor eyesight, losing your hearing or memory?  Are you at risk of falling?

If the answer to any of these questions is yes, you are the 2011 definition of a leper. Face it, if I am accountable for how well you handle an illness, and for what your outcome is, I cannot afford to treat you unless you are highly compliant, have no other risk factors, and stand a 99% chance of getting well.

Francis is 69 years old, has smoked for 30 years, has COPD, and early dementia.  She is admitted for her third heart attack and I am responsible for the outcome of her hospital care.  On the third day of heart hospital admission, Francis gets out of bed to get a cigarette her son snuck in (because he loves her), she falls, hits her head and chokes.  The nurses get her back in bed and assess her injuries.  Her wrist is broken and needs to be set.  During her stay she develops pneumonia.  She is treated and discharged one week later.

Rather than being paid for Francis’s care, her physician is held responsible for her poor hospital outcome.  According to the Tribune, the broken wrist and pneumonia will be blamed on poor care.  The doctor should have anticipated  Francis’s fall and restrained her (restraining a patient is actually illegal).  Francis has no culpability.

As a matter of fact, Francis persists in smoking; it’s her God given right.  She is readmitted eight days later as her COPD has worsened, challenging her heart.  Re-admissions are also the doctor’s fault and another black mark goes on her doctor’s report card.

Francis is a leper. ACO’s are not new.  They are HMOs on steroids.  In the heyday of HMOs, doctors treated patients like Francis as if they were playing Hot Potato.  They pushed them out of their practices.  Scott Sarran, MD, a VP with Blue Cross, is quoted as saying, “We are strong believers in aligning incentives and paying for value.  We pay them for outcomes rather than paying for procedures and visits.”

Your doctors are smart.  They have spent many years in classrooms.  If their incentives are realigned from the current day “caring for the patient” to the future, “caring about quality outcomes,” you had better believe that they will achieve those outcomes.  If their patients’ individual foibles and bad habits get in their way, those patients will have to go somewhere else for care.

The modern day leper will be you or your neighbor.  Who will care for you?  If ACOs take hold, there will be very few private docs, there won’t be enough cash-paying patients to sustain their practices.  I have consistently called on my patients to take personal responsibility for their health.  Stop smoking, stop drinking and start exercising.  Those who are healthy will love the new system.  Of course, they will rarely access the ACO as they won’t need to.

Those who are not healthy and have not taken care of themselves will hate the new system.  They will find it devoid of care. They will be a liability, a leper of sorts. While I have never met a leper, my understanding is that their care was inhumane.  Think about Dr. Sarran’s comment, “strong believers in aligning incentives …”  No place in that statement was the word “care”!  Your doctors’ incentives are being realigned.  You better realign your own health goals now. You don’t want to be a leper.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • Dr B

    sigh…. very nicely and simply put and so so very sad. I have been screaming this ever since “pay for performance” was introduced. and they think we have “healthcare inequality” now!! it can and WILL get much worse.
    why have we done such a miserable job of explaining this to our patients? they will have no idea what has happened until they are railroaded (in about 5yrs, I figure.)

    Why do we as physicians continue to stand on the sidelines and let the politicians decide the fate of healthcare in this country??

    we used to be leaders in the community, now we are just civil servants with no benefits or pension. I think i’m going to go back and be a fireman…. at least I can claim a pension.

  • Dr B

    sigh…. very nicely and simply put and so so very sad. I have been screaming this ever since “pay for performance” was introduced. and they think we have “healthcare inequality” now!! it can and WILL get much worse.
    why have we done such a miserable job of explaining this to our patients? they will have no idea what has happened until they are railroaded (in about 5yrs, I figure.)

    Why do we as physicians continue to stand on the sidelines and let the politicians decide the fate of healthcare in this country??

    we used to be leaders in the community, now we are just civil servants with no benefits or pension. I think i’m going to go back and be a fireman…. at least I can claim a pension.

  • Doc99

    Mr. Chambers, don’t get on that ship. “To Serve Man” – It’s a Cookbook!

  • Doc99

    Mr. Chambers, don’t get on that ship. “To Serve Man” – It’s a Cookbook!

  • Anonymous

    I’m confused. Who is at fault? The system for trying to find a way to continue paying for care for all (note your example patient is Medicare age) when FFS is an obvious failure; the HONDA patient (Hypertensive Obese Non-compliant Diabetic Alcoholic) who, for the past 30 years, has ignored all warnings and continued to smoke and thus developed the COPD (and expects Cadillac care for Yugo dollars); or the doctors, who upon realizing that the patient has no “skin in the game” and therefore isn’t going to make significant changes to improve their own care decides to push said care somewhere else (most likely to the hospital) to save their own sagging revenues?

    • http://pulse.yahoo.com/_2WRDURQNAS45UF6Z7ZYHYBUOQA TEA

      it.s not really the “grouping of physicians and caretakers so that they have a common goal of improved health for the patient” that is the problem.  an ACO in theory should be much better in healthcare.  we see this in many examples.  it’s the convoluted way that congress has decided to pay these groups that is the problem.  

      it has ALWAYS been about the payment system.  fee for service doesnt work.  payment for outcomes is not going to work (for reasons stated above.)  

      until a system pays doctors to focus on the sick instead of shun them… it’s going to be bad.

      why not create a system that allows a doctor to choose…..  either take care of LOTS of healthy people, or take care of less people that are really sick.  both would make similar money but one would focus on high turn over healthy pts while another would focus on low turn over chronically ill and sicker pts (but would have to see less of them.)  
      those systems exist and would be easy to implement.  but go figure…. no one has even thought about those in the halls of congress.

  • justanadminguy

    I’m confused. Who is at fault? The system for trying to find a way to continue paying for care for all (note your example patient is Medicare age) when FFS is an obvious failure; the HONDA patient (Hypertensive Obese Non-compliant Diabetic Alcoholic) who, for the past 30 years, has ignored all warnings and continued to smoke and thus developed the COPD (and expects Cadillac care for Yugo dollars); or the doctors, who upon realizing that the patient has no “skin in the game” and therefore isn’t going to make significant changes to improve their own care decides to push said care somewhere else (most likely to the hospital) to save their own sagging revenues?

    • http://pulse.yahoo.com/_2WRDURQNAS45UF6Z7ZYHYBUOQA TEA

      it.s not really the “grouping of physicians and caretakers so that they have a common goal of improved health for the patient” that is the problem.  an ACO in theory should be much better in healthcare.  we see this in many examples.  it’s the convoluted way that congress has decided to pay these groups that is the problem.  

      it has ALWAYS been about the payment system.  fee for service doesnt work.  payment for outcomes is not going to work (for reasons stated above.)  

      until a system pays doctors to focus on the sick instead of shun them… it’s going to be bad.

      why not create a system that allows a doctor to choose…..  either take care of LOTS of healthy people, or take care of less people that are really sick.  both would make similar money but one would focus on high turn over healthy pts while another would focus on low turn over chronically ill and sicker pts (but would have to see less of them.)  
      those systems exist and would be easy to implement.  but go figure…. no one has even thought about those in the halls of congress.

  • Margalit Gur-Arie

    But the guy from CMS just said that doctors want ACOs:
    “Blum said some of the recent media attention on the government’s
    attempts to establish ACOs has taken a negative spin. However, among the
    1200 comments CMS received on the proposal, many doctors commented
    favorably.”
    http://www.healthcareitnews.com/news/cms-director-says-doctors-want-acos

    Who commented favorably? What am I missing here?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    But the guy from CMS just said that doctors want ACOs:
    “Blum said some of the recent media attention on the government’s
    attempts to establish ACOs has taken a negative spin. However, among the
    1200 comments CMS received on the proposal, many doctors commented
    favorably.”
    http://www.healthcareitnews.com/news/cms-director-says-doctors-want-acos

    Who commented favorably? What am I missing here?

  • Anonymous

    I know my mother did not live the best life with all the right choices. I don’t expect Doctors or the system to jump through hoops for her. All I wanted was an attentive Doctor to approve hospice at the end of her life. But could you do that for me? No. Why not? That is the accountability and you failed.

    Don’t worry doc, you and your group have plenty of money and I am sure ACO’s will get shot down.

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