April 25, 2011
Accountable Care Organizations (ACO) will be sold as the savior of modern medicine. They are the brainchild of Medicare and the first ones are slated to begin January 1, 2012. The basic premise of ACOs is that medical costs are too high and, given “proper incentives,” a fully integrated network of primary care physicians, specialists and hospitals can reduce costs, saving Medicare a lot of money. A “proper incentive” is allowing the ACO to share in the money that it saves Medicare. Of course, if the ACO does not save Medicare any money but instead costs it more money, the ACO will have to share in that expense as well.
This week, Medicare announced that an ACOs share of the savings will be based on “quality, cost and patient care.” I think it is significant that patient care is a distant third on the list. Medicare is finally showing its true colors.
Quality, number one on the list, is one of those nebulous words, highly marketed and often worthless. I suspect quality will be measured in terms of the ability to generate statistics on anything but quality of care. How long did you wait to get an appointment? How long did you wait in the lobby? How long did you wait to see a nurse? To get a phone back from the office? All very important quality measures.
Cost, number two on the list, will be managed by the ACO. As things stand today, your local hospital chain will be your ACO. In Chicago, ACOs are likely to be Advocate, Evanston Northwestern, and the University of Chicago, all highly rated medical systems. Currently, these hospital corporations earn their profits by admitting you to the hospital and running the expensive tests I wrote about yesterday. You, the patient, are a valued customer.
As a patient of an ACO, the situation is drastically different. The ACOs make money by “controlling costs.” How do ACOs control costs? Simple, they limit the number of expensive tests and procedures that they do by requiring the physicians in their ACO to use “protocols.” “Protocols” are just a fancy word for prescribed treatment and diagnostic regimes for the average patient. (I’ve never met an average patient, but I am told they do exist.) The primary care physician (PCP) will be your main contact with the new medical system and will use protocols to decide what kind of treatment you get. In essence, your PCP will be a “gate keeper” determining whether you get to cross the border from illness to health based on nothing more than an algorithm designed to control cost. Rationing anyone?
Third on the list is patient care. Yes, I said “third” on the list, and yes, patient care will be addressed. I’m afraid patient care will be measured by how well the doctor followed “protocol” – the new standard of care. Patients will receive care based on the best medical evidence, not necessarily what is best for the individual patient. Medicare, the insurers and the ACOs will decide what the best evidence is. The employed physician will have it easy, no thinking necessary – just enter the patient’s information into the computer, apply the protocol and out pops the treatment plan. The ACO will provide the evidence, the protocol and all the physician will need to do is follow the yellow brick road. Look Dorothy! We’re not in Kansas anymore!