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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