THCB

Pete Seeger’s Blues

There I was, going one-by-one through a list of doctor and hospital groups that had volunteered to be one of the “accountable care organizations” authorized by health care reform, when I inexplicably found myself breaking into song. I know: it’s a really strange way to react to ACOs, but bear with me.

You remember, “This Land is Your Land,” don’t you? Written by Woody Guthrie in 1940, it caught the folk music wave of the 1950s, and has been sung ever since by performers ranging from Pete Seeger to Johnny Cash. Odds are you at least know the first verse:

This land is your land, this land is my land

From California to the New York Island

From the Redwood Forest to the Gulf Stream waters

This land was made for you and me.

ACOs are not obviously song-worthy, although they are significant. One of the Affordable Care Act’s signature initiatives, they initially drew bipartisan support as far back as…well, 2010. In April, the government announced that thousands of doctors serving more than 1.1 million Medicare beneficiaries had voluntarily joined ACOs, giving up fee-for-service reimbursement for some patients in exchange for a paycheck that’s based on measurable standards related to high-quality, cost-effective care. They’ve made the switch because it’s the right thing to do and because they’re getting ready for a day when Medicare’s fee-for-service money dries up.

But I was not singing about financial savings.   What inspired me was geography. At a time when political hyperventilators portray Obamacare as an evil government plot, the diversity of locations where ACOs have voluntarily formed shows that people outside Washington know that health reform is about making care better.   So get out your guitar and follow along with me:

From California, the ACOs include Sharp HealthCare, situated in San Diego (where the local GOP boasts that “the Republican Party is proud to be the majority party“), and HealthCare Partners, a Southern California mega-medical group sprawled over a political landscape ranging from ultra-liberal to ultra-conservative.

To the New York Island, which has my favorite ACO, the Chinese Community Accountable Care Organization, serving the elderly population of New York City’s Chinatown. It’s a locale that undoubtedly includes illegal as well as legal immigrants. There’s also a Bronx ACO (not technically on the New York “island”), but alas, no ACO for Little Italy, the Lower East Side or Spanish Harlem. I also searched in vain for, say, a Palm Beach ACO for affluent retirees who’ve gone from a golf handicap to a real handicap.

From the Redwood Forest. Really, who besides gnomes, sprites and a few tree huggers lives in a redwood forest? Fortunately for the nature-loving elderly — perhaps aging ex-hippies worried about their artificial hips? — there’s the Heritage California ACO, whose eight-county area includes the redwood forests of San Luis Obispo.

To the Gulf Stream Waters. This one was easy: the Accountable Care Coalition of the Mississippi Gulf Coast. No word on whether its doctors are conveniently located near the slot machines of a local casino.

So there you go: This land was made for you and me.

The moral of this story is clear: Americans who love this great country should sing out their support for Obamacare and ACOs. If Woody Guthrie’s left-wing past concerns some would-be crooners (I’m looking at you, Antonin Scalia — we know you sang in a chorus before joining the Supreme Court), they can comfort themselves that “This land is your land” has been embraced by the Mormon Tabernacle Choir singing along with the United States Air Force band. You don’t get more patriotic than that.

Speaking of patriotism, look at this version of “This Land is Your Land” with a background track by Bruce Springsteen underscoring a speech by a guy who’d just won the 2008 Democratic presidential primary in Iowa.

No red states, no blue states — just the United States of America. Woody Guthrie and the Air Force band. Hey, Supremes, sing it out for Obamacare: “This land was made for you and me.”

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age. This post originally appeared at opednews.com.

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Joe Flowerpaulsouthern docBarry CarolMD as HELL Recent comment authors
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Joe Flower
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> just the fact that you would quote a guy like Joe Flowers (a self proclaimed “expert” with no actual medical experience) who has about as much practical knowledge about medicine as my Golden Retriever is kind of embarrassing. This is to say that the only thing there is to know about the management of healthcare is what a doctor knows: How to diagnose and treat a medical condition in a patient. This is to say that there is no possible expertise or thought or analysis about the economics of healthcare, the management of large complex organizations, the politics of… Read more »

Barry Carol
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Barry Carol

“I just don’t understand why I should be tasked with saving bucks/increasing profits for the insurers. If insurer X pays one doc $500 for a procedure and another doc $2000 for the same procedure, why should I spend my time saving the insurer from their own stupidity?” Payment differences don’t exist because insurers are stupid. They exist because certain providers like well known academic medical centers, large physician practices that are associated with them and some hospitals in less populated areas among others have enough local or regional market power to command higher rates even though their care quality may… Read more »

paul
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paul

A quick comment about something posted way upthread —

“In fee for service the physician is employed by the patient.”

Where does a pure fee-for-service environment exist anymore, outside of Medicare and the few people with health savings accounts? For most people, their health care is covered by insurance, and so, technically the physician is employed by the insurance company.

Barry Carol
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Barry Carol

“(Actually, doctors’ fees are the smallest part of the expenditure mess, and effort would be much better spent elsewhere).” Southern doc — If you look at a breakdown of medical claims for the typical commercial insurer, you will find that about 40% of claims are for hospital charges, both inpatient and outpatient, another 40% is for physician and clinical fees, and the other 20% is for prescription drugs. The fact is that doctors’ DECISIONS to admit patients to the hospital, prescribe drugs, order tests, refer to specialists, consult with patients and perform procedures themselves drive virtually ALL healthcare spending. I’ve… Read more »

southern doc
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southern doc

“I think doctors need to include the wise stewardship of society’s limited resources as part of their job and knowing who the most cost-effective high quality providers are and steering their patients to them is a critical part of that.” But that only applies to primary care docs, right? We’re the ones who should spend our time pouring over spread sheets to figure out which specialist in which insurance plan is cheapest for which condition. I just don’t understand why I should be tasked with saving bucks/increasing profits for the insurers. If insurer X pays one doc $500 for a… Read more »

Barry Carol
Guest
Barry Carol

Rob – I think any payment system can be gamed, at least to some extent, by clever people. The area where I see considerable room for improvement, whether we stick with the fee for service model or move more toward capitation and bundled payments, is for referring doctors to do a better job of ensuring that patients get necessary and appropriate care from the most cost-effective high quality providers. To do that, you will need good easy to use price and quality transparency tools. Doctors will also need to incorporate knowing and caring about costs as an important part of… Read more »

southern doc
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southern doc

Why is it that when a problem is identified, it always becomes the responsibility of the few remaining primary care docs to fix it? If we think we pay specialists too much, just pay them less. I’m not the one writing the fee schedules, so don’t drag me into it. (Actually, doctors’ fees are the smallest part of the expenditure mess, and effort would be much better spent elsewhere).

BobbyG
Guest

Dr. Rob @ May 19, 2012 at 3:46 pm “My “opinion”(and I’m not saying I’m right) is something I never would have advocated 20 years ago, and I know I will get flamed for this(and thats OK), is that everyone in this country deserves access to quality, affordable health care. I think that even with ALL the problems, and their are many(both theoretical and practical) but on balance the only way to achieve that goal IMO is Universal Single Payer Health Care. Not ACO’s or HMO’s or capitation. We need to cut out the middleman, the businesses and insurance companies… Read more »

MD as HELL
Guest
MD as HELL

Go Rob!! They are still ignoring the patient. Manageing the disease is easy if you have control of all the variables. The largest variable is the patient. If ObamaCare wanted to manage the patient, it would have them going towards the cliff. but they leave that to the Republicans to try.

Dr Rob
Guest
Dr Rob

Yes, you are a very good quoter! Any other names you would like to drop? Do you get credibility because you quote people? Do you have any original ideas of your own or do you just believe everything you read? I am board certified in 3 specialties and have been practicing medicine for over 20 years and am chief of medicine at one of the hospitals I practice at. Does that give me the right to an opinion? What are your credentials, quoting other authors?

BobbyG
Guest

Of course. What’s your proposed solution? I’m still waiting to hear it. My credentials, feeble as they may be, take all of about 5 seconds to find. No, I’m not a physician, so I guess that renders me irrelevant in your eyes, just like it does Joe Flower. Spares you the trouble of actually reading his works and evaluating his ideas. “I am board certified in 3 specialties and have been practicing medicine for over 20 years and am chief of medicine at one of the hospitals I practice at.” Wooooo..o.o.o.o.ooo…. Who’s the braggart here? Even stipulating that you indeed… Read more »

Dr Rob
Guest
Dr Rob

Bobby G: you are the king of the cut and paste! The comments section is usually reserved for original comments and not to regurgitate the thoughts of others as you do(at least you give the authors of your posts the appropriate credit). With regards to who the braggart is, if you read your previous post: YOU ASKED ME! I will however take you at your word because I do believe that YOUR credentials ARE as you put in your own words” feeble”. At least going forward people will now be able to judge your comments on your experience and background(None).… Read more »

BobbyG
Guest

My zero background and experience? Flatter yourself. And, what, are you also now the comments policy police here? Now, can we get to your reform proposal? I asked for that at the outset. What would in your view comprise an efficient, effective, affordable, just, and sustainable health care system? FFS hasn’t cut it. ACOs, which you summarily deride, haven’t even gotten off the ground yet, and may indeed may end up being Son of HMOs. Should SCOTUS strike down the PPACA in toto, ACOs go down with the ship. The problem won’t go away. Why don’t you redirect your energy… Read more »

Dr Rob
Guest
Dr Rob

My “opinion”(and I’m not saying I’m right) is something I never would have advocated 20 years ago, and I know I will get flamed for this(and thats OK), is that everyone in this country deserves access to quality, affordable health care. I think that even with ALL the problems, and their are many(both theoretical and practical) but on balance the only way to achieve that goal IMO is Universal Single Payer Health Care. Not ACO’s or HMO’s or capitation. We need to cut out the middleman, the businesses and insurance companies that are pulling so much capital and resources off… Read more »

Dr Rob
Guest
Dr Rob

Share the risk? THATS your solution? We had share the risk 50 years ago when you paid for your health care out of pocket and then got reimbursed for a portion of it by the health insurer. I guess everything old is new again. How does that reduce costs and ineficiencies of the medical system? How does that improve medical outcomes, reduce overhead and waste? BTW just the fact that you would quote a guy like Joe Flowers(a self proclaimed “expert” with no actual medical experience) who has about as much practical knowlege about medicine as my Golden Retriever is… Read more »

BobbyG
Guest

Right. No one comes even CLOSE to YOUR ostensible acumen.

At least I can check out his rap sheet.

Are you even really a physician?

“just the fact that you would quote a guy like Joe Flowers”

How about Dr John Toussaint? — MD.

I can quote him at length as well.

How about Jerry Reeves? — MD.

I can quote him at length as well (He’s my senior medical director).

How about Brent James? — MD

http://www.bgladd.com/IHC_CQI_certificate.jpg

Give it a break, “Dr.”

BobbyG
Guest

@Dr Rob May 18, 2012 at 7:09 pm “Oh there are plenty of solutions” Not that you are offering any. ___ Joe Flower, “Healthcare Beyond Reform” Share the Risk Risks and rewards drive behavior. If players in any system are not doing what we think they should be doing to make the system work well, chances are they are not getting rewarded, or put at knowing risk, in a way that matches their effect on the system. In economics, risk does not mean uncertainty. Uncertainty means that things may be different in the future in ways that you can’t know… Read more »

Dr Rob
Guest
Dr Rob

When you boil it down, ACO’s are really a sophisticated form of capitation, which by the way failed miserably in the 1990’s. But here we go again! In fee for service the physician is employed by the patient. In an “ACO” the physician works for the ACO and the patient is merely a distraction. The physician will be financially rewarded and incentivised if they withold care or provide the least amount of care. Remember in the new world of “ACO’s” the physicians will be taking a financial risk and will be rewarded for witholding treatment. A patient that expires on… Read more »

BobbyG
Guest

Yeah, but you fail to acknowledge the “outcomes” emphasis, which was not a concern of the HMO model. The aggregate dysfunctional upshot of the FFS paradigm is by now rather blaring.

Dr Rob
Guest
Dr Rob

Outcomes? I guess you are as naive as the author of this article. ACO’s will learn to game the system in their favor and to maximize their profit. A patient develops a ventilator associated pneumonia? No, no, no code it as gram negative tracheobronchitis and the idiot bean counters won’t figure it out. Patient discharged prematurely from the hospital for CHF needs readmission because they were given inadequate treatment? Just code it as acute renal failure with fluid overload. Outcomes! Really? You must have been born yesterday if you think a FOR PROFIT ACO won’t figure out how to game… Read more »

BobbyG
Guest

Right. No less an eminent health care thinker than medical economist JD Kleinke has noted that sustainability going forward will be “manage the DISEASE instead of managing the money.”

So, Dr Rob, I guess there’s just no solution, because gamers will continue to game any system.

Dr Rob
Guest
Dr Rob

Oh there are plenty of solutions, just not this one. It hasn’t been thought all the way through and no one is expecting any of the the unanticipated consequences of an “ACO”s model of delivery. It remains a “theory” of a system that is completely untested and relegates patients to “widgets” that ACO’s will attempt to move through the health care system by any means necessary to enhance their bottom line and maximize their profitability. If you think that the business of medicine is soleless and profit driven now, just wait: you aint seen nothing yet!

Paul Bleiweiss
Guest
Paul Bleiweiss

As the Practice Manager of a solo Micro IMP practice that does not want to be part of some huge multi level ponzy scheme… My wife’s Family Practice as a matter of fact I have a question for everyone who thinks that ACO’s are at any level a fair or appropriate thing to “Force” upon Physicians and other providers of Medical Care…. Why at any level is it fair or appropriate, even really Legal to force licensed practioners into joining an organization that leaves them in ANY way or form responsibly for and absorbing ANY of the Risk, the Skin… Read more »

BobbyG
Guest

OK, fair enough.

And, your solution is ___________________________________?

(1,868 words or fewer.)