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.

24 replies »

  1. > 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 healthcare, the pricing of drugs and devices, the influence of population pressures, targeted vs. blanket information in epidemiology, the influence of education on population size, the emerging bacteriological science on the roots of obesity, the incorporation of patient safety studies into the architecture of large medical campuses, or any of the other subjects I have tried to wrap my ahead around over the last thirty years.

    Thank you for the gentle corrective.

  2. “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 be no better than their less powerful competitors.

    The biggest potential for savings here comes from avoiding the high cost hospitals for the procedures that every hospital can do well. Imaging that can be scheduled well in advance is far cheaper at a non-hospital owned imaging center than in a hospital owned facility. Generic drugs are cheaper than brand name drugs for the same condition.

    Once you know that hospital A in town is generally cheaper than hospital B or C and just as good, you don’t have to spend any time pouring over spreadsheets. The same goes for the non-hospital owned imaging center. Presumably you already prescribe generic drugs instead of brands when they’re available or at least don’t check off the DAW box on the prescription form unless there is a good reason.

    One alternative would be more widespread use of tiered and narrow network insurance products. Then you would just have to know whether the referred provider is in the network and/or which tier he / she / it is in.

    Don’t get me wrong. If the price and quality transparency tools were readily available, patients should do their part to find out the cost of care ahead of time and comparison shop to the extent feasible. Of course, care that needs to be provided under emergency conditions is a separate issue. In that case, no hospital should charge an uninsured patient more than 150% of Medicare, period.

  3. “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 procedure and another doc $2000 for the same procedure, why should I spend my time saving the insurer from their own stupidity?

  4. 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.

  5. “(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 been a consistent advocate for user friendly price and quality transparency tools to allow both patients and referring doctors to identify the most cost-effective high quality providers. 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.

    If there is a shortage of primary care docs or will be in the future, it would also be helpful to allow NP’s to practice at the top of their license without physician supervision. However, the doctors’ lobby typically opposes that idea as they do every other idea that threatens to impinge on their turf. They’ve fought competition at every turn for decades and continue to. I don’t see how that will help to mitigate cost growth either.

    Dr Rob –

    While I can appreciate that a single payer healthcare system would likely make your administrative life easier and you might not need as much support staff as you have now, highly regarded experts like Dr. Ezekiel Emanuel, now at the University of Pennsylvania, oppose it. He and others believe it would lock in most of the rigidities of the current system and would stifle innovation.

    Medicare is a single payer system for the elderly and many of the disabled. It was in existence for 40 years before it even offered a prescription drug plan which private insurers offered for decades. It has 20% coinsurance for Part B services with no out-of-pocket maximum. It pays high and low quality providers the same amount for a given service, test or procedure. It’s riddled with fraud. It overpays for some services like cardiac care and underpays for others like primary care. I don’t think it’s a model worth expanding beyond its current scope.

    Only Canada and the UK have a single payer system while Germany, France, Netherlands, Switzerland and most other developed countries use insurers, albeit non-profit insurers, to negotiate rates with providers and pay claims.

  6. 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).

  7. 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 their job whether the payer is the taxpayer, a commercial insurer or the individual patient. If it were up to me, patient benefit statements would also include how much money in total was spent on the patient this year as well as how much has been spent cumulatively since he or she had insurance. High utilizers would get extra scrutiny from insurance company case managers with (paid) help from PCP’s.

    Other ways to attack costs that are independent of individual doctors and the payment model include more advanced and aggressive use of analytics to mitigate fraud and tort reform that would give doctors safe harbor protection from failure to diagnose lawsuits if they follow evidence based guidelines where they exist.

    Patients can do their part by executing living wills or advance directives and sharing them with family members so if the patient can no longer communicate and the end of life is near, both providers and family members will know what care the patient wants and doesn’t want.

    While I know that capitation certainly creates an incentive to withhold care in order to increase profits, under fee for service, there are plenty of doctors that are money driven even if you are not one of them. I think the biggest problem, though, is with the hospitals. They’re the ones that are killing us financially, especially those with the local or regional market power to drive reimbursement rates up faster than their costs are increasing year after year. That’s got to stop.

  8. 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 that are pulling so much capital and resources off the table that could be directed at taking care of people. When you are sick the last thing you should have to worry about is obtaining access to the system or losing your house or life savings.”

    Thank you, sir. Well, no flames from me on that proffer. See my october 2011 post “ACOs? “Another Crock of, uh, Government”?”


    I’m certainly no unreflective cheerleader for any of this byzantine stuff.

    The PPACA was mostly about insurance regulation re-jiggering that suited the for-profit AHIP crowd, all of the proposed process reforms trying to wean us away from FFS were secondary. The middlemen seem to have a Gucci Gulch death grip on patients, clinicians, and government alike.

    We’re making progress Dr. Rob. Thanks. Seriously.

  9. 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 the table that could be directed at taking care of people. When you are sick the last thing you should have to worry about is obtaining access to the system or losing your house or life savings. I have witnessed too many financial/medical tragedies to see this continue. I know that my practice would likely take a financial hit(on the other hand maybe I would be compensated at some minimal level for the daily charity work I do and it would be a wash), but either way the status quo is not sustainable. ACO’s are not going to fix that for just some of the reasons I discussed earlier. So we can all hold hands and sing kumbaya or a Bob Sieger song as the author advocates but it is naive to think that ACO’s are going to be the savior of our medical delivery system.

  10. 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 there instead of dissing me.

  11. 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). I don’t think I need your permission to state my opinion I, think I’ve earned that right(in fact I’m sure of it).

  12. 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 have all the clinical cred you claim to have doesn’t by extension mean that you have a clue regarding what would make for rational and more effective health care delivery and payment policy.

    I’m still waiting to hear some ideas.

    BTW, while I’m citing stuff that I’ve “read,” how about a few notes on the blog post author, Michael Also-Not-A-Physician Millenson:

    “Millenson is the author of the critically acclaimed book, Demanding Medical Excellence: Doctors and Accountability in the Information Age (University of Chicago Press), now in its third printing. He also serves as a senior adviser to the Information Technologies for Better Health program of the New York-based Markle Foundation. Millenson, often a lightening rod in attempts to move public policy, has recently written an article in Health Affairs (Vol. 22:2) entitled “The Silence” and subtitled “Medicine’s continued quiet refusal to take quality improvement actions has undermined the moral foundations of medical professionalism.” Millenson was also featured prominently in a Washington Post feature article by Sandra Boodman entitled “No End to Errors,” a three-year follow-up to the IOM report.

    National Public Radio called Millenson “in the vanguard of the movement” to measure and improve the quality of medical care. He is regularly quoted by the news media, and his articles have appeared in such peer-reviewed publications such as The Journal of Health Politics, Policy and Law and Health Affairs, as well as in general-interest publications such as The Washington Monthly and the World Book Encyclopedia. He has testified before Congress and the Institute of Medicine of the National Academy of Sciences, and he gave testimony on May 27, 2003 before the Federal Trade Commission on the sharing of reliable hospital quality or care information with patients. He has also lectured at the National Institutes of Health, Yale School of Medicine and Harvard’s Kennedy School of Government.

    From 1996 to 2001, Millenson was a principal in the Health Care and Group Benefits practice of William M. Mercer, Inc. From 1994 to 1996, he was a visiting scholar at what was then Northwestern’s Center for Health Services Research and Policy Studies, where he wrote his book under an Investigator Award in Health Policy Research from the Robert Wood Johnson Foundation.

  13. 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.

  14. 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?

  15. 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


    Give it a break, “Dr.”

  16. 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 kind of embarrassing.

  17. @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 and can’t do anything about. You are uncertain what your healthcare premiums might be next year, but typically you have no way to affect those premiums. On the other hand, you are at risk for things that you can do something about. If you have a business, you put money at risk when you invest it in the business because if you can manage the business well, you can make a profit.

    Risks in a traditionally insurance-supported fee-for-service system are wildly ill-distributed. The insured patient has all the personal risk of getting sick or dying, but none of the financial risk, because the healthcare is all paid for up front. The patient who overuses the system (whether a patient with first-dollar coverage or a homeless person with no coverage ending up in the emergency room) has no financial risk in using the system.

    The doctor or clinic, on the other hand, has almost all of the knowledge and resources, but very little of the financial risk. The only financial risk for the doctor or clinic is how much activity the business generates—how many office visits, tests, and procedures patients bring in.

    The health plan or the government has almost all of the financial risk, with limited abilities to control that risk. However, what is at risk for the payer is not the actual cost of healthcare, but only the spread between that cost and the funds it receives in the form of premiums or taxes. As long as the payer can take in more money than it pays out for care, the payer is financially healthy.

    Here’s the key point: no one in the system is at financial risk for producing the best outcome at the lowest cost. Unlike other businesses, in traditional insurance-supported fee-for-service healthcare, no one makes their living by providing me, the customer, with what I need. There is no feedback loop serving to drive costs down and waste out of the system.

    Is it possible to rebalance risk in healthcare to make it work better and cheaper for everyone? Yes, at the personal level and the system level…

    … In the 1990s, as the Clinton healthcare initiative failed, a new fad arose in the battle to control costs. Insurers looked at Kaiser and other staff model HMOs (health maintenance organizations with salaried doctors on staff) that combined the insurance function with the clinical delivery. The organization took in one premium payment from the individual (or the individual’s employer) and provided whatever the individual needed, from a flu shot to brain surgery. In this capitated model, the HMO took on the financial risk of delivering the promised healthcare for the price of the premium. “Ah!” said insurance companies, “Perfect! HMOs! That’s what we’ll do! We’ll call it ‘managed care’ and do it a little differently. Since we have all the risk anyway, we’ll be like Kaiser and control the clinical side as well, and drive down costs. Bingo!”

    This was actually a good idea—but it is not what they did. Managed care turned out to be quite a different animal. The HMOs that the insurance companies built in the 1980s were not real, staff model HMOs. The doctors did not actually work for the HMO. There was no clinical integration, there were no teams, there was no tracking of quality or outcomes. What there was instead was cost control by contract, with primary care installed as gatekeepers to specialists and all services beyond the primary care office, and all physicians working at discount rates. Primary care physicians were paid bonuses to deny treatment by other physicians. It was called managed care, but there was no real care management, only cost management. It was just a variation on the same business model insurance companies had always had: avoiding risk by avoiding treatment whenever possible. Patients hated it, doctors hated it. It was, in fact, exactly the kind of interference with clinical medicine by Soviet-style functionaries that the insurance companies had told the public that healthcare reform would bring. We had a Soviet-style system, it was just outsourced to the private sector. Once consumers and employers experienced this form of discount healthcare, the rush to managed care slowed, and the hunt continued for a true, systemic way to find value in healthcare.

    Only in the last 10 years have we seen the slow growth of more subtle and flexible…

    …So why don’t we just capitate all healthcare (the industry term that means “pay for all of it in one big lump sum, whether through a single-payer system or through insurance”) and let the provider take the financial risk? I get this question too in public forums. This is the argument for a truly socialized system like Canada’s. The answer is easy to see: anything that is completely free of cost to the user becomes overused. Canada’s provinces have struggled for 50 years with this. They have no way of holding down demand, so they have to hold down supply—which results in the horrendous wait times, and the difficulty of getting high-end services, that Canadians often complain about.

    The answer that has emerged over the last two decades is to get the end customer to take on some risk, a carefully titrated amount of risk for using the system, through deductibles and copays and specialized health savings accounts. Intelligently designed high-deductible health plans matched with health savings accounts and the right set of incentives are proving to be a workable way for the consumer to accept some financial risk.

    Even fully capitated systems like Kaiser have introduced deductibles and copays on most plans. As a patient, deciding to go to the doctor will cost you some money. But it shouldn’t cost you too much money, or you’ll skip going at all, and end up with a worse problem.

    On the other hand, Kaiser does not make its living on those copays. It makes its living by delivering all the customers’ healthcare for less than the customers pay in. So a visit to a Kaiser primary care doctor can be highly efficient. When I recently asked my doctor to look at a tiny bump on my hand, I also ended up with a full physical, prescription renewals, and three vaccinations, all in about 40 minutes. Neither the doctor nor the system would benefit from making me come back for separate appointments for all these different elements.”

    Flower, Joe (2012-04-24). Healthcare Beyond Reform: Doing It Right for Half the Cost

  18. 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!

  19. 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.

  20. 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 the system to maximize their bottom line.

  21. 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.

  22. 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 the first day of their ICU stay also has the lowest length of stay and causes the least amount of debt to the ACO. ACO’s will very quickly learn to game the system in their favor, very likely to the detriment of their patients but in favor of their pocketbooks. I know if I was hospitalized I would want a payment system that rewards a physician for keeping me alive instead of a system that rewards care givers for saving the “Organization” money!

  23. 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 in the outcomes of medical care???? Espcially since they are NOT the ones who will have ANY control of some of the most important factors that influence those outcomes….

    Do we control Big Pharma the cost of the Medicines we might feel best to write? Do we contro the Formularies that the Health Insurance Carriers create mainly to save them “quarterly” profits and not really based upon real outcomes…. We all know that ten different carriers can’t have 10 different policies on therapies, meds and proceedures all supposedly based upon “Research” and best of Science and all be correct… Some or most of them have to probably be wrong if one of the others is correct…

    We do not control their employers nor their work enviornments hours nor their potentially abusive bosses and supervisors. In other countries in Western Europe and in Canada there are actual with teeth, supported by honest Psych and Social research laws against bullying known better as Mobbing in the work place and it is the leading cause of “going postal” around the globe. The stresses lead to PTSD and all the physical health problems that come with it, auto immune, vascular and heart disease of MI’s and Strokes no less the triggering of real Psych like problems and symptoms…

    We don’t even control their wages or their hours… So with so much forced OT and other bizzare issues, how is a single mom running from work to the day care center or after school program going to drag a hungry cranky toddler or grade schooler to first go to the grocery story, afford to pick out the best of food from the produce isle and lean proteins and the like and then go home and cook that better healthy meal??? Or will that stressed, hurried and over worked mom simply do what way too many Americans do these days, pick-up a Pizza or do the fast food drive thru as a form of dinner multiple times a week????

    Do we have Orwellian means of observation and control over this patient that we might at best see 2 to 4 times a year???? School teachers complain and rightfully so I might add that even though they have the kids for 5 days a week for about 5-6 hours on those days, they can not over come the home enviornment after those kids leave their control and where they have access to them… Is it suddenly now the Teacher’s responsibility if the kids DON’T do their Homework because the parents don’t support that, make the kids turn off the X-Box, the TV, the Computer if and until their homework is done first???? So why then is how and what our patients are exposed to, forced to do via the greater society that we all presently work in, no less what that “Free Willed” human being chooses to do, suddenly and now perhaps forever “Our” responsibility and that we are suddenly “Their Mothers” forever more??? Now with our careers and paychecks directly tied to how well we can figure out a way in a free society with Cigarettes and Booze no less other less legal or advisable substances floating around to “Control” them and make them shape up or better yet, force them, make them, fool them into “Shipping Out”??? To say our skin and our falling bottom line???

    Anytime in modern history that schemes have been created to try and link physician pay to patient outcomes or use the bottom line has always been more work and paper work with lower pay for those doctors while shareholder profits for the Insurance Carriers and or HMO’s went up and up….

    Care managment from the top down with the main goal of “saving money” especially when only measured within the myopic view of healthcare dollars only doesn’t work and never has and never will. Dividing up a patient and their care, their “case” between multiple care givers be social this or specialist that…. it is the real full out primary care doctor finally with time and space, breathing room financially and mentally too, that can best solve these problems…. Let that PCP be the social worker of sorts as well as the care provider of the medical and mild Psych too…. Pay them really well and allow them to bill properly for phone calls, follow-ups, over sight and other care…. BY THE HOUR just like our other Super Control us Docs upper professionals the LAWYERS get to do… So a doc can capture being paid and treated respectfully for all that they can and would do if compensated properly and the outcomes will start to flood us with positive numbers and increases in quality and quantity of life….

    We are NOT insurance carriers and we should NEVER allow ourselves to absorb or otherwise be conned into starting to become them either. Funny, how when a private cash only doc wants to start a membership based practice to keep the practice small and provide Best Practices of care for their small panel… almost any and all of the states have come after them with all guns blazing because supposedly they are “Selling Insurance” as is the case here in NYS…. But find a way to pay back election campaign promises of increasing profits and reducing overhead for their buddies in the Health Insurance industry and suddenly being part of “Really Aborbing and Assuming” high levels of Finacial Risk based upon Medical Outcomes is perfectly fine and dandy to these same kind of selfish Pols and their supporters….

    Charge a modest $350 membership fee for being a patient on your panel and the wraith of the gods comes down upon your head as selling insurance because you are “Assuming Medical and Financial Risk” and therefore you are violating health insurance law and selling insurance without a license and not meeting the thousands of guidelines too for being allowed to do such for your network and the like….

    But join some huge ACO with added levels of garbage and employees to keep the damn thing going and afloat and to collect your data and report your data and retrieve your payments based upon that data and defend that data….. and start to assume all too real very high levels of risks to let the gov’t and the Insurance Carriers off the hook for that risk… The risk that naturally comes from insuring the Health of the Independent Thinking and Acting, can’t be predicted or well controlled, Human Animal who is at the heart of the entire thing…. Well then that if just fine and dandy and A OK with the states and the feds then….

    What part of being healthcare providers and not Health Insurance Carriers and or Health Risk Absorbers don’t any of you Band Wagon Jumpers get…. My parents raised me in the 1960’s on the likes of Pete Seeger, Phil Oches, and Woody Guthrie and both they and Woodie would be appauled at this latest new screw the doctors for the betterment of the Rich Share Holders Scheme. And they would be ashamed of you for falling for it so easily and hook line and sinker like too….

    Woodie would have supported the idea that Insuring and Caring for all of our Citizens was an entire society’s job and responsibility, some form of Medicare for All with perhaps Doctors being well compensated Employees who were allowed to Unionize and stand-up for what they believed in for both themselves and their patients’ best interests, as the highly skilled and trained labor that they were and are…. Woodie would have wanted doctors to be at the most Direct Helm of the Healthcare boats rudder creating commitees of docs to create best outcome panels based upon their best clinical understandings of the latest research of the time…

    No less the fact that as the sufferer of a terrible genetic disease himself that could be passed on to his future generations that slowly rings the life out of the person and leaves the less and less able to care for themselves; I think that Woodie best of all would have understood the stupidity and insanity of Privately Held, For Profit Insurance Carriers with Bloated Boards and Execs no less the Federal Gov’t too, of passing on the all too real risk of the financial impact of the care of any given patient or patient population to “The Workers” further on down the line with less control and power over so many of the items and policies that will effect the final outcome of the product that those workers were producing.

    In closing I don’t think that Woodie would have wanted to slowly waste away all the while knowing that his genetic disease that neither he nor his doctor had much if any control over, was none the less negatively impacting his doctor’s income, his ability to feed and support his family, pay off his or her staggering Med School Debts (owed to more 1% bankers, CEO’s and Shareholders) no less might be denying them funds and cash flow to properly run their practice or clinic which then would negatively impact so many of the patients that came after him and his problems, his genetically aquired disease state…

    You’re right “This Land is Your Land and My Land”…. It is time for doctors to join the forgotten good fight of the likes of Phil Oches and Woody Guthrie, Pete Seeger and the Weavers too… To start demanding Real, Viable Solutions that stop making the Primary Care doctors who have sacrificed so much over the past 30 years attempting to care for the masses all while in the face of the horrible Mess the Gov’t and the Private for Profit Health Insurance Carriers and their friends in the other For Profit parts of the industry have done to Medcine and done to those doctors and all of our Citizens…. It is hight time we took our nation back from the greedy few and started to create solutions that take proper good care of one and all… both the service providers who provide that needed care and all of our Citizens that need all of that care that we in medicine can and want to provide, if only the greedy SOB’s and Clowns who have inserted themselves in the middle would simply get the heck ouf of the way…

    And so, the ending question I have for you and any other ACO band wagon jumper is this… in the words of Phil Oches:

    “Which Side Are You On Boy, Which Side Are You On????