Will physicians be caught in the ACO web?

I’m a big fan of the current Direct TV ads. One of my favorites involves a guy who goes to a self-help seminar, becomes overconfident, goes to Las Vegas and loses everything, and has to sell his hair to eat. The ads are all based around the theme of avoiding making mistakes by becoming something that you are not intended to become.

I think there is much for doctors to learn from these ads and apply to the current opportunity with Accountable Care Organizations or ACOs. I think we could easily write an ad that says “don’t be attracted by money from evil people seeking to co-op you into their schemes to make themselves more money because when you do you sell your soul, you are owned by a devil.” I think we need to recognize that many devils exist and are trying to get us to sign up to sell our souls to them.

During the PHO debacle a few years ago, I reminded our physicians that the letters should represent the ownership and direction that these organizations should take as they developed. I frequently offered that they were really pHO’s with Big hospitals and Big organizations with little physician control over the direction and quality that was important to us.

I fear that the same is true with ACOs. If we are not vigilant in their formation and direction, then they will become AcOs with physicians being a small part of their governance but very accountable to their owners. They will be dependent on the revenue streams that spring from them. I see scenarios where physicians will profit but then be caught in a spider’s web of their own design where they will be told how to practice and what kind and amount of care they can provide. I guess you could claim that I don’t trust insurance companies and you would be wrong. I do trust them. I trust them to do what is best for the corporate profits and the nonprofit executives’ with bonus clauses at the end of a successful year.

I’ve been around for a while and lived through the evils of the uncontrolled HMO and the Physician Practice Management Companies and the various schemes that have attracted physicians like small fish to an archer fish’s light. While my personal opinion is that this period in our history represents perhaps the greatest opportunity for physicians to recapture the leadership role they long ago abdicated, real dangers exist that could make physicians little more than indentured servants doing the bidding of their overlords.

Physicians need to be smart and develop business acumen and, for once, teach the business world that physicians can be and should be good business people as well as great doctors. One of the great lessons I’ve learned through the years is that other physicians are not my enemy. We may disagree, but most of us have the interest of our patients at heart. I would not make the same assumptions about other organizations or interest groups.

I went to medical school out of a desire to participate in the care of my patients. I love seeing my patients. I love being their advocate and their guide through the maze of what we call a healthcare system. I still see patients every week and work hard to provide them with good care. I try to provide the type of care I would provide my own family members. I have no doubts that I am not perfect, which my wife reminds me of on a regular basis, but I do work hard and deeply care about the profession and the patients I have given my life to for the last 30 years. It’s from that background that I have developed severe concerns about the current ACO structure.

My personal vision of healthcare is a return to a system where my focus is on the contract to provide high-quality care between my patient and myself. I always remember an older general surgeon who used to tell me about the days when he practiced medicine without the interference of insurance companies and administrators who knew more than he did. I always listened and envied him for working in an era when the patient was his only focus.

I think a return to such an era is possible and economically feasible. The patient centered medical home has demonstrated what high-quality primary care can provide as an impact to save unneeded and expensive care that often had poor results. The concierge model of practice has demonstrated that alternative economic models can thrive and provide better patient satisfaction and access to care.

The challenge is figuring out how to combine new approaches with old models that provided high-quality care and make them work. However, if we are not prudent in our evaluations, I suspect we will look like the coyote in the Road Runner cartoons: we have built an elaborate trap that our target has eluded and we ourselves are trapped in a system of our own construction.

Kerry A. Willis is family physician and Chairman and CEO, The Beacon Company/Atlantic Integrated Health.

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