ACO

Are the Accountable Care Organizations defined in the health insurance reform law something that RA patients need to be concerned with?  On one hand, ACO’s deal with Medicare, so don’t directly affect people who aren’t on Medicare.  On the other hand, anything my doctors spend their time and energy on has the potential to affect the care everyone gets, so we all have a stake in the game.  Any policy on healthcare has the potential to spread to other areas, affecting us all.

Regardless of whether you were for or against the health care reform legislation, the creation of Accountable Care Organizations is one portion of the new law that is particularly puzzling.  Everything I’ve read about it makes me say, “That’s not new.  It sounds like an HMO.”

Instead of acting independently, doctors and hospitals are to form partnerships to oversee patient care, and will spend thousands (millions?) of dollars to jump through all the legal hoops of getting the ACO set up.  New employees will need to be hired to deal with the added workload.  Computerized medical records are a must for Accountable Care Organizations, so every member of the ACO will be required to spend money on EMRs that will talk to one another.  That’s a pretty costly experiment!

In most businesses, people make investments when spending that money means they’ll be able to earn even more money.  Not here.  The goal of ACO’s is to reduce the cost of medical care.  Reducing the cost of medical care means that the hospital/doctor/testing facility will earn less money.  From a financial standpoint, I can’t for the life of me figure out why medical providers would spend massive amounts of money for the privilege of taking a pay cut.

What about on the patient side of the equation?  People who want an HMO have Medicare Advantage; people who don’t want an HMO go with the fee-for-service option.  Now ACOs will take those fee-for-service patients and force them into the renamed HMOs.  Patients may also find that they’ll be seeing less of their doctor, since people seem to believe that in ACO’s doctors will be required to act as administrators overseeing mid-level providers who do the actual patient-care.

Another problem is that patients with health challenges might find it difficult to get a doctor who will care for them.  There are goals – for instance, diabetics should keep their bloodwork in a certain range, people with hypertension also have a target range in which their blood pressure should fall.  One of the reasons that ACOs are required to have an EMR is so that they can send reports to the government on how these patients are doing.   If labs and blood pressure fall within the goals, doctors get a bonus.  If patients aren’t doing as well as the national standards recommend, then no bonus.  Some pay for performance models are even reported to dock physician’s pay when patients don’t meet goals.

Notice that doctors lose pay when patients don’t do as well as desired.  How stupid is that?  Doctors can only diagnose and suggest a treatment plan.  They don’t follow patients home and supervise the exercise regime.  They don’t hand patients their medicines three times a day and watch to make sure the pills are swallowed.  They don’t police their patient’s dinner menus.  It’s the patient’s responsibility to carry out the treatment plan.  It would be much fairer if coverage were restructured so that patients had 100% coverage if all treatment goals are met, but only 80% if they’re only close to the treatment goals, and maybe only 50% coverage if it’s obvious that the patient is making no attempt to live a healthy lifestyle.  Pay doctors fairly for their work, and give the financial rewards/penalties to the patients based on how successfully they implement their treatment plan.

Under this ACO system, doctors will eventually drop patients who aren’t doing well.  Why take $25 to care for someone who isn’t meeting the treatment goals and takes lots of care (time), when it’s possible to be paid $50 for people who don’t need as much care and don’t need to be seen as often?  It’s not that the sicker people will cost less to care for, it’s that they won’t be able to get care at all.

That really scares me.  When doctors can be better compensated for cherry-picking healthy people, instead of taking care of those who truly need medical help, we should all be concerned.