ACO 552: The Advanced Class

flying cadeuciiLisa Bari, a Master of Public Health candidate at Harvard, attempts to take me to ACO school in her response to a piece I wrote. I welcome the discussion.  Game on!

Lisa’s initial point, and the one she ends on, seems to say my argument falls apart because I somehow don’t understand the difference between a commercial ACO and a Medicare ACO.  I beg to differ.  She states that CMS cannot be held responsible for a commercial non-governmental agreement between a private insurer and a group of health care providers.

I guess you do need to go to Harvard to decipher this stuff.  Is the implication that the only ACO model the architect of the ACOs are responsible for is the initial Pioneer model? It makes no sense.  To recap:  CMS was instructed to create ACO’s. There are 2 programs to do this.  The Pioneer model, and Medicare shared savings program (MSSP).  As I understand it, the large regional ACO next to me is set up as part of the MSSP.  Someone makes a payment to these ACOs when there are cost savings, right?  By the end of her first paragraph, one almost has the impression that ACO’s are a renegade program that emerged from thin air between insurers and health care providers. Yes, a commercial insurer decides to make an agreement with an ACO and they set a $4 rate. I guess I am to assume if the govt/CMS did it directly it would be much more.  And I do realize that ACO’s are for PCPs, and not designed for specialists.  The only reason I think I have any ‘contract’ at all is because I have a PCP I work with.  My point with regards to the ACO payment was that I have no clue where that $4 is going – but that compensation for care coordination at that level is inadequate, and would require quite the mix of healthy:sick to make that work.  Is there another number you can give me so I can take an opinion on the matter – or should I just continue to trust our fearless leaders?

My main point of contention is actually not the $4 but it is the Harvard study on the results of the MSSP program so far. The central point remains: There is so far nothing to support the idea that ACO’s will save the country money (wasn’t that the main point?).   I will give you that it is early.  Perhaps the ACO’s will start to save bags of money at some point, the overall health care cost curve will be bent, and I will once again feel good about voting for ACO’s twice.  But, I’m not an ideologue and I’m having trouble seeing how exactly ACO’s will work on the ground to cut cost.  So when I saw this study come out, it validated my concerns – and it should serve as a warning.  At some point someone decided the emperor was wearing no clothes – and I’m getting very concerned that ACOs at this point are going commando.

By the way, this is not the only piece of data to sound warning bells.  Lisa discusses the Pioneer model of ACO’s glowingly, but fails to mention the fact that 32 ACO’s began in 2012 under the Pioneer umbrella.  By Nov., 2015 only 16 were left.  That’s right-50% of ACOs dropped out, and the available results would suggest that they dropped out because they were going to lose money.  The ‘Nextgen’ ACO model may optimistically sound like Version 2.0, but the cynical side of me suggests this is a desperate way to save the ACO model because left alone it was going to pieces.  It is a tough predicament for the ACO founders to be in – they need to save money, but in order to make ACO’s attractive to be in, they have to throw more money at the problem.  Apparently the Nextgen program will allow for 100% of the cost savings to accrue to the ACO as opposed to 50%.  That’s great.  Perhaps 50% of ACO’s won’t drop out in 2 years.  I still have no idea how exactly this will be cost effective for us, the public that pays the taxes that goes to these brilliant constructs.  The important point the authors in the Harvard study make is unassailable, and is a fact: When you account for the bonus payments made to the current MSSP ACOs, there is NO net savings to the government.

Lisa does launch into the usual bromides about our current model being unsustainable. Clearly anything is better than this – even if its worse.  Never mind that Lisa conveniently brushes aside the fact that health care cost increases from 2009 – 2013 were flat compared to GDP rise in that same time span.  You are reading that right – health care costs stayed right around 17% of GDP in the current fee for service construct for four years.  2015 saw the first uptick, and the reason according to CMS was expanding enrollment due to the ACA.  Apparently subsidizing health insurance for millions of people costs money.  The savings that were supposed to offset this expanded coverage were supposed to come from reduced payments to medicare advantage plans, and yes ACO’s (among other things – read my prior post).  Costs, instead, have gone up, care delivery from the ground level seems mostly the same to me, and some little guy like me who is running around attempting to do the right thing is being advised to cease and desist.

Do I think there’s a solution ? Absolutely.  We do not have to pay 17% of our GDP for care that’s mostly equivalent to the rest of the developed world.  I don’t have a single solution, and I do have lots of ideas – but one of the clear problems I see on a daily basis is that John Q Public wants a lot of stuff.  I did not think it ‘ham handed’ as Lisa suggests, to suggest that we should have a national conversation about the cost of care as we currently deliver it?  The current fantasy is that we can have everything without having to pay for it.  This can only happen in the richest country in the world.  I was just asked about placing a defibrillator for primary prevention in a 70 year old man who had suffered a significant stroke.  The expectation from our patients is that everything is possible.  This is an illusion.  It would help if we spoke about – yes – rationing care, if we want to spend less.  As long as we continue to place defibrillators in debilitated 70 year olds without batting an eye, all the three letter acronyms in the world will not result in lower costs.

Finally, and I really do mean this with all the politeness I can muster, Lisa really does not have a clue when it comes to talking about care coordination.  Mrs. K is very much a real patient, who has had a kidney transplant, chronic kidney disease with a baseline creatinine that hovers around 2.0, severe aortic stenosis, with a mean gradient over 40mmHg, and systolic blood pressures that started out around 200mmHg.  She was sick enough to be hospitalized under my care, and was seen by me every day she was in the hospital.  I spoke to her PCP before admitting her and asked her if she would like to take care of her in the hospital with me consulting.  She politely demurred.  Now a few days after getting home the patient was calling me – as she should.  I went over her weights at home, what her blood pressure was currently running, what her last creatinine was, how she was feeling, and subsequently made a decision about medications, when to repeat lab work, and when to follow up.  Where exactly do you want to insert the PCP/case manager/health coach into all of this?  Believe me, as someone who does this a lot every single day, a PCP is incredibly, and yes centrally, important to the care of patients.  There are quite a few things I am not paying attention to with regards to Mrs. K, and her PCP is vital to the process.  However, to expect a PCP to primarily manage these aspects of this patients care is laughable.  I have to restate this – you want that Saturday morning call on this complex cardiac patient to go to a PCP, a case manager or health coach.  If you find  any one of those three who will take that call, please let me know.

Lisa ends with the usual unhelpful hand-waving pronouncement about ushering in a world where ” care providers, in partnership with patients are asked to be more accountable for the high cost of health care”.   And this, folks, is why we fail.  The brightest among us come up with these completely meaningless statements.  Apparently MACRA will get us there – all we have to do is check enough boxes, engage patients with patient portals, and sprinkle in a health coach or two.  Lisa’s post does serve one very important purpose – if it doesn’t convince physicians and patients that we are firmly on the wrong track, I’m not sure what will.

Well perhaps this nugget from another non-clinician will:

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28 replies »

  1. Really useful! This is perfect and all the details show how well thought of it is. Thank you.

  2. Your title to the the previous article was literally throwing Dr. Koka under the bus–“he got it all wrong”!!! i.e., he’s such a rube, he can’t undertsand ACO’s!!!
    YOU name called and denigrated first. As a physician I must tell you point blank, I don’t care if you like physicians. I don’t care if you dislike physicians, it’s a free world. What you must understand is that you THINK you know best, and in your arrogance you’re going to dictate to those who are in trenches and have the expertise and qualifications to cure disease what to do, and how, and why–and yet you believe we’re arrogant for simply being the doctors of medicine.
    I choose an anonymous alias as is my right, and indeed, as another physician commented here, we are targeted by Big Brother and physicians do not have freedom of speech online. We cannot defend or address a bad Yelp review, because HIPPA. We are subject to ritual beheadings if we say the wrong thing in print or otherwise. It is my prerogative. I am not hiding, merely protecting my identity as I have been advised to do by my malpractice carrier.

  3. Dr Koka–don’t sell yourself short. We must all be leaders and strong in the face of enemies who wish to destroy medicine. As a fellow physician I appreciate your piece more than you’ll ever know. I believe it the height of arrogance when non qualified non physician folks tell us how to behave, how to think, and how we’re so wrong and don’t know what we’re talking about–and above all they dictate to us how to be physicians. When WE have the qualifications, training and experience to save lives, how are we arrogant in making this declaratory statement? They throw the rocks at us first. We have to throw the rocks back. No more M. Nice Guy (or Gal). Yes, it is a war now, the clinicians vs. the administrative bureaucrats. Bring it.

  4. Appreciate the passion. I dare say we wouldn’t be in this predicament if we had more folks like pesto sauce. Clearly what must be battled is the narrative that high value, low cost care will naturally emerge with adoption of any technology that’s ‘certified’, patient engagement, etc. These ideas didn’t originate from folks like lisa and steven – I’m fairly sure it is our colleagues who have told them this. Steven also reminds us that our physician advocacy groups have essentially endorsed value/outcome based care. These groups that supposedly represent us don’t question whether or not to measure, but rather what to measure. Little surprise then that Steve and Lisa take the positions they take. At least they choose to engage in a discussion with us serfs. The same can’t be said of our physician representatives..

  5. Names? because of big brother. We are monitored for everything. The last thing we need it to be told is that some regulating body decided to re-read my comments back to me for some credentialling or board certification or whatever, or an attorney reads them back to me at a depo. And yes I have heard that happening. Once they re-read our webpage back back to us asking about some procedure we had on there. We live in a very different world than you know.
    Defensive medicine? at least 20% the total costs.
    End of life over care? I am pretty sure that medicare has those numbers, in that the cost of care for medicare patients in the last week of life is something like 10-50X the cost the entire years of care prior.
    Patients demand care and treatment, we do not admit, refer patients that have NO issues, they all have problems. But the workup and tests may always be elevated 20% for defensive reasons. Even if every MD got zero dollars, patients would be admitted, referred, tested, etc. The biggest cost driver is disease not the doctors pen. You can regulate the hell out of physicians but you are now at a wall, we cannot take it anymore. And if you drive us out, it becomes a MUCH bigger nightmare for everyone. Because once we are gone, we’re gone.

  6. Meltoots – Thanks for the informative comment.

    I was wondering if you have a guesstimate of the percentage of medical costs that are attributable to defensive medicine and how much could be saved if we had a more reasonable litigation system in which doctors reasonably perceived that they would only be sued for something egregious like wrong site surgery. I also wonder about the extent to which physician practice patterns developed by the specialty societies themselves incorporate the reality of our litigious society by including testing that might not typically be done in other developed countries.

    I have the same question about the cost of what I would call unreasonable or even futile care at the end of life because families can’t let go.

    Regarding healthcare costs more generally, I note that while doctors only account for 20% of costs under the standard definition of cost categories, their decisions to admit patients to the hospital, order tests, prescribe drugs, refer to specialists, consult with patients and perform procedures themselves drive virtually all healthcare costs that insurers pay for. In short, the biggest cost driver is the doctor’s pen at the end of the day. No?

    Finally, I’m curious about why a lot of smart guys, especially doctors, who comment here don’t use their real name. I use mine because I think if something is worth saying, it’s worth owning up to.

  7. Yeah, its your choice to put your real name on this. Lisa, you should expect more blowback as providers are inundated from all angles with people assessing them. We are tested to death, MOC’d, certified, attested, audited, sued, rated online, berated by everyone that the system is costly…when the vast majority of the costs are way out of our control. Imagine today that someone with no idea what its like to practice on the front lines, determines that you need to use their computer program, pay for it, then you have to data entry every little thing you do, follow a coding program that makes no sense to get paid, then hope to be paid, then get rated online about your work, we penalize you if you don’t comply, we rate you, assess you audit, sue you if what you are doing is costly, doesnt work, etc. You would be mad as hell too. We have had enough and are not going to take it anymore. We do not want to hear about more and more complex regulations to ratchet down our pay, when everyone else can crank up their costs with no controls, like big pharma, IT, patient factors, etc. Its time to stop penalizing the doctor for everything. How about we assess the quality of what YOU are doing, what CMS is doing, maybe the physicians will decide the standards. When no physicians are left, or only those that are zombied by the system, don’t come crying that you want us back.

  8. Thanks, Steven. I certainly do not view this as docs vs non-docs – many of my excellent professors and classmates are doctors or medical students, and in my pre-MPH life I had some excellent doctors and clinicians in my acquaintance. There is no health care without doctors, but also no health care without the rest of us. Dr. Koka and I have engaged in a respectful, ideas-driven manner with a little bit of humor as well.

    I hope that interested people, docs and non-docs, will take a look at what is being proposed in the MACRA. Now is the time to comment and engage with the proposed rule.

  9. Dear “Pesto Sauce” – I noted your many comments on this and the previous post. It’s one thing for me to write a post under my own name, it’s another for you to hide behind an avatar to attack me personally. My post and the subsequent replies were written in the spirit of debate (and my post originated from a request for a counterpoint by the editors of The Health Care Blog). Dr. Koka and I have engaged in a respectful manner with a little humor as well, which is ideal.

    I’m getting my MPH because I care about public health and I enjoy health policy. Per your earlier accusation, I left my job to pursue the graduate degree. I thought that my joke about Harvard was more obvious–I may be “at” Harvard but I am not “of” Harvard. I’m an equal-opportunity agitator, I’ll challenge the stances of academics, health economists, doctors, pharmaceutical and hospital executives alike. I’m from rural northern California and I’ve been all over this country (and others).

    And finally, I like doctors, but I also like nurses and other medical professionals. I like behavioral health providers who are excluded from so much of the conversation. I even like businesspeople, research scientists working at pharma companies, hospital administrators, and state and federal government policymakers. What I don’t like is the us against them attitude and the people who think that doctors shouldn’t be subject to any quality standards, or believe that doctors don’t respond to incentives like any other human being.

    On this forum, we’re talking about ideas. Personal attacks are entirely inappropriate.

  10. Allan – I understand that. At the same time, pure fee for service provides incentives to provide too much care. Since the U.S. has a more entrepreneurial culture than most of the rest of the world, there will be lots of doctors who, at the margin, will be interested in making some extra money by providing more care that is, at best, only marginally useful. The extra care also has the benefit of providing more protection from lawsuits in our overly litigious society.

    Doctors are really smart people. They have to be to get through medical school, residency training and, if they’re specialists, fellowship training. I don’t understand why they are unable to convince policymakers that leaving them alone to take care of patients WITHOUT BANKRUPTING SOCIETY would be the optimum approach to patient care.

    It’s pretty obvious to me that the society can’t afford to have medical costs increase two percentage points faster than nominal dollar GDP growth each and every year forever. It’s unsustainable. Presumably, all these government initiatives that doctors hate are a response to that trend notwithstanding the slowdown in medical cost growth that we’ve seen since 2009.

  11. it’s an analysis of the analysis of the analysis. Dr. Makary moans and groans because he can’t get funding for studying medical errors. here it is
    google british medical journal med errors
    Medical error—the third leading cause of death in the US
    BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2139 (Published 03 May 2016)
    Cite this as: BMJ 2016;353:i2139

  12. So you’re getting your MPH so you can join the central planners. And a quick search online told me who you are. You have no credibility in this forum. The professionals with decades of training –that’s right the dirty word y’all hate, doctors!! –have the expertise to treat and cure disease. In fact, we’re so good at it, that millions are living into their 90’s and breaking the backs of the financing of that medical care. You are the mouthpiece of the machine, spewing the need for health coaches and systems to provide care, but these systems aren’t optional, they’re being codified into law and MANDATORY without proof that they work. It’s a grand experiment that is showing signs of failure. I respectfully suggest you hang out in your local clinic, ER or get in your car and get out of the northeast and see for yourself what America is like beyond the ivory tower.

  13. Agree 100%. Where’s the MACRA for the EHR that paralyzed care? Where;s the pharma MACRA? Patients not getting prescriptions, and draconian preauthorizations I spend hours dealing with, and no drug–thanks Mr. Shkreli.
    oops, silly rabbit, it’s all about central planners wanting to destroy doctors and control the system top to bottom.

  14. Right on Dr Koka! Where are the health coaches coming from who are going to navigate the nuances of pharmacology, physiology, and patient psychology to field the phone call on a Saturday morning? Oh, I forgot, they already exist, they’re called DOCTORS. In your case, a specialist–cardiologist. Bravo for speaking truth to power.
    Ms. Bari doesn’t grasp the severity of illness and the complicated co-morbidities we’re dealing with as fast and as accurately as we can. No other “provider” entity–pharmacist, health coach, can handle this, even PCP’s are too harried and full of complicated patients they can’t be expected to know every bit about in the 7 minute visit.
    The central planners have no qualms about cutting the payment to doctors wholesale and brutally. There is no courage to tell the public, if you want the new hip, you have to pay cash. If 94 year old great grandpa falls on his head and is rendered a vegetable, we can’t do dialysis on him. I know personally from family in Europe, this is how it is there. You get a basic level of care, but if you’re old and have really complicated bad situation, you don’t get the hip, defibrillator, valve, etc. This is where the huge spending is happening in the US and this is what’s bankrupting Medicare.
    Bureaucrats and politicians lack the courage to tell the truth. So instead they demonize the deliverers of the services, with no tort protection from WITHHOLDING the service because it costs too much in the ACO.
    As regards to “poor values we’re getting for our health care dollar”. It’s a medical care dollar. There is no health care dollar. The populace isn’t getting the message–or getting the money to buy spinach and exercise. They’re forgoing vaccines and screenings because “all those crazy doctors are going to make mistakes” and give their kids autism.

  15. Barry, the incentives behind the ACO and the HMO are pretty much the same. Forget about just a bit of medically necessary care and profits will rise. If the patient dies there will likely be no damning record of the physician involved, but there will be tremendous savings when the chronically ill die.

  16. Well its gonna be doc vs non-docs soon, as the non-docs are killing the docs with these experimental programs. ANY experimental program should NOT penalize those that do not want to partake. Policy driven markets do NOT work, ie HITECH/MU. We can try new ideas and the US government should allow ANY and ALL innovation, not just their complex prescriptive ideas. Hence STOP penalizing us. Forget AMA and ACP etc, they do not represent the front line providers, and they know this. Rationing HAS to be brought up, as its the most effective method to reduce cost. They other option appears to the current method of driving every sane physician to insanity and out of practice and you will ration indirectly as there will no one left to see you. As for Big Pharma, sure we see some public outrage by the Shrekeli’s that raise the price of medications from cents to $1000 dollars, but technically, he is lawfully allowed to do that. And in many ways, big pharma does that ALL the time, on less of an obvious scale. Where’s their MACRA? Their price controls? Similar for implant companies, IT departments/vendors, etc. Shouldn’t CMS declare that a certified EHR cost only $1 as its critical for patient care? Shouldn’t EHR vendors have to PROVE that they are providing EXCELLENT products, usability, support, efficiency, safety and security? Why shouldn’t they get MACRA’d on quality cost advancing care info, and improvement activity? And if the provider satisfaction is below 70 percent with EHRs, which it is currently for most EHRs, shouldn’t they be penalized?
    How about the patient? The noncompliant patient that gets readmitted? Should the patient be required to pay more if they are a smoker, etc.?
    Why always blame the provider for increased costs? I dare anyone to choke down the regulations of MACRA, both MIPS and AAPM. AAPM is the most confusing complex disaster ever unleashed on us. MIPS is not far behind.
    How about everyone that makes these rules. If you make these rules, where is your MACRA? If you make things worse for providers, worse for the patient, worse for cost and healthcare, then maybe the designers of these programs should have to report it and attest and get penalized. Or maybe your non-doc job. How about you report your activities? See how you like it, especially when the costs of your job, are mostly out of your hands. Lisa, Steve, how about I decide what I think you should measure, make you pick 11 objectives, by my certified software, then I’ll pick some quality measures for you to report, like 6 or so, then a few Improvement activities, otherwise, I am docking your pay 9 percent. And too bad, I think this is great for you.
    Sure you can tell me to quit or stop taking Medicare, or whatever, but you would lose someone that takes 31 years to make again. Thats 14 of training and 17 of direct clinical experience. Might take awhile to make another me. So be wary of telling all of us to get out or stop taking Medicare. I am one of 4 ortho surgeons left at our hospital that started with 30+ ortho surgeons 17 years ago. When I’m gone, I’m gone. Don’t cry to me when you cant get into see someone or get your broken ankle or hip fixed. Thats the rationing thats coming, and fast.

  17. I’d hate to think this is evolving into a docs versus non-docs debate. I know many docs who would side with Lisa here on the system failures that persist and the poor value we are getting for our health care dollar.
    That said, this is a debate worth having. Dr. Koka makes many valid points about the disconnect between reform ambitions and the reality of everyday patient care. It’s tough out there.
    But I’m mostly with Lisa here. We have to push new systems of care and we have to have greater accountability. We ARE is an experiment phase. Some things won’t work. Docs are welcome to come up with their own ideas, locally and nationally. The AMA, ACP and others are starting to realize that and it’s why they mostly supported MACRA.
    Raising the specter of rationing is not helpful or needed. By all accounts, we waste 1/4 to 1/3 of our health care dollars. Redirecting even half of that to appropriate, needed and judiciously delivered care would obviate the need for any rationing—and allow all the 80 year olds who want/need a new hip to get it.
    Of course it’s also “the prices, stupid,” as Uwe Reinhardt long ago pointed out. We see that again in this week’s study on overcharging by non-profit hospitals. Prices for health care goods and services in the US are way higher in US than other countries after currency adjustment, etc. Insurers and government need to stop paying inflated prices! And fast. I know that’s not as easy as it sounds. And remember: Medicare reimbursement over 50 years has been an incredible tax financed cash cow for your industry and bank accounts.
    Thanks to both Anish and Lisa for taking the time to engage in this debate.

  18. Barry, There was an article in the WSJ just a few weeks ago pointing out that some states are re-acquiring Medicaid and doing it themselves again. Sorry I can’t find the cite.

  19. When I met with the specialist who performed by last high tech intervention, he specifically said that he considered me a LOW RISK candidate for the procedure — non-smoker, normal weight, no diabetes, etc. The prior two interventions were the direct result of the findings from angiography. Indeed, the second one, a stent insertion, was performed on the spot when the blockage was discovered.

  20. Absolutely we should be able to practice without any complex regulatory activity by CMS and ONC. Its burdensome, meaningless and not helpful to anyone. Including Medical Errors. If MU and all those CMS/ONC regulations are so great, they why do we still have medical errors? After 6 years shouldn’t we be basking in the glow of improved safety?
    Aggregate data also does not tell you the whole stop on quality and cost, opiods etc.
    1. Cost, in the US, medical liability drives the cost of medicine up WAY more than any real quality problems. Defensive medicine is real and will be forever until we have a national dialogue on that. If you Lisa, could lose your entire savings, home, investments, etc on ONE bad outcome, I think you may be more understanding of defensive medicine. Anyone on the front lines has seen excellent physicians dragged through that process.
    2. In the US, I daily see patients in the hospital that the patient is 97 year old, demented, that has a life ending disease, that the family wants full court press to solve their problems. Its time to have a national discussion about end of life, and rationing care.
    3. WITHOUT a doubt, anyone that goes from fee for service to salary does EVERYTHING they can to minimize work to get the same salary. Its human nature. Its Capitalism vs Communism. If you want to call the IRS about some tax questions you have, don’t expect a call back, or someone staying late, or personal attention, they have NO incentive for doing work. Fee for service is NOT the enemy.
    4. Opiods…A big driver in this is patient satisfaction surveys and rating physicians online. You cannot believe how many people come to the doctor and EXPECT narcotic pain medication for their aches. If we tell them no, and even explain why, they will rate or say that they are not satisfied. It happens ALL the time. I always say be wary of the 5 star physician out there. They are giving out Percocets like candy.
    5. Propublica recently posted the best hospitals and doctors for hip and knee replacements. In our state we were the number one in TKA (total knee) and number 8 in THA (total hip), in the entire state of Ohio for highest quality/lowest complication rate. Its just 2 of us doing TKA and THA at our hospital. We do not do MU and get penalized by CMS. Yep we are the among the highest quality, lowest complication rate physicians in the entire state, and the best in TKA. Do you think maybe CMS would not penalize us? Nope. Because we do not do their silly programs, we get penalized… but we take damn good care of our patients. And we are not the exception.
    6. Do you really think MACRA is going to salvage the EHR disaster laid upon us? DO you think adding Clinical Practice Improvement Activity really will help me do a better job? do you really think reducing burden is from 18 objectives to 11? Renaming it helps? Puhlease. I use a NON certified EHR that is customized to our practice and we do a killer job taking care of patients. Maybe CMS should DROP the certification requirements for EHR, let innovation return and let providers work with vendors to get what we need to improve usability, safety, security, efficiency, outcomes, and overall care/satisfaction. And in the end that will definitely reduce cost. Not some jiggered up Advanced APM or ACO model, with 900 rules and regs. Its caring doctors working directly with technology and patients to make things work. I do not need a nanny state policy wonk to tell me how to do it.

  21. Money was also saved as more and more states bid out much of their Medicaid business to private insurers. At a meeting I attended last week, Kansas Governor, Sam Brownback said when he took office in January 2015, he moved Medicaid beneficiaries into private insurers. While Medicaid costs continue to grow in Kansas, they are doing so from a base that is fully $1 billion per year lower than it was before the private insurers were brought in. Managed Medicaid is saving states money across the country as more and more states have adopted it.

  22. If we could do value based medicine right – sure. As I repeatedly have said – I was all for it and voted for this. It’s a problem of implementation. Also the narrative of the specialist complaining because of income threat is too simple. Value Based care would support my colleagues that do this and penalize those that dont. Lisa – that’s not happening. I’m just not clear we are going to measure our way out of this. Measuring value turns out to be very hard, especially if folks like me don’t have a seat at the table. I’m not an ideologue and I don’t think you should be either. If it doesn’t work, let’s find a different way. And I absolutely think folks like u need to be a part of the solution – hopefully you and your colleagues don’t take my comments as suggesting your exclusion.

  23. Firstly – I’d like to thank Dr. Koka for an entertaining ACO debate. I love to engage with people on ideas, and I think we’ve hit on an important one here.

    I think that our health care system must transition (fully) to value-based care, and finally leave fee-for-service behind. That means the incentives have to change, and that the center of the system has to shift. I was alive in the 80s and 90s and I remember HMOs from personal experience, and I know the criticism. Specialists didn’t like PCPs as gatekeepers, and I get it–this limited the volume of services they could provide and in general exerted downward pressure on their incomes. HMOs also had incentives to stint on care, and patients rightfully hated this as well. We must find a new way to deliver care that aligns the incentives.

    He notes that health care costs remained flat from 2009-2013. I wish that this was due to some type of fee-for-service efficiency, but unfortunately it was not. It was during this time that reimbursements to doctors under Medicare were cut 2% across the board (the Balanced Budget Act), combined with a recession and an increase in the number of high-deductible health plans.

    Dr. Koka doesn’t think my perspective is relevant because I’m not a clinician, and I can respect his opinion here while also strongly disagreeing. I have experience shaping the kind of technology platform that he and nearly all clinicians use, and I believe in user-centered design, meaning that I don’t want to build it or sell it if the actual end-users (the clinicians) can’t figure out how it works. I’m on the clinician’s side here, and I know that most systems aren’t built this way. I lived through Meaningful Use. I’ve talked to many hundreds of doctors, nurses, billers and patients. There is a place for clinicians, policymakers, administrators, technology vendors and perhaps most importantly, *patients* in the healthcare world, and our perspectives are all valuable. However, if more clinicians don’t get involved in the policy world in a meaningful way (and I don’t mean commenting on blogs), we won’t be able to find better solutions.

    Here’s my ask: please learn about the MACRA. CMS is in a “listening” phase. They tried to simplify all of the quality reporting and incentive programs and make it easier for clinicians to report and get feedback. Starting on Monday the 9th, the “notice of proposed rulemaking” (ok, we’ll never get away from governmentspeak) is open for public comment. Please read the many excellent summaries that are starting to leak out, and please comment on the issues that are most important to you. Here is the link to comment: https://www.federalregister.gov/articles/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-and-alternative-payment-model-incentive-under
    And here are the first decent summaries I could find, from the AMA of all places: https://download.ama-assn.org/resources/doc/washington/2015-05-07-hr-2-detailed-summary-branded.pdf and https://download.ama-assn.org/resources/doc/washington/sgr-bill-comparison-chart-hr2-vs-current-law.pdf

    Under the MACRA, they’ve allocated $20M/year to help smaller practices report on quality measures and deal with technology. One thing I’d ask for is more money here – and an extension to the successful “Regional Extension Centers” that were used in Meaningful Use. There are plenty more important points to comment on.

    Lastly – here’s something I’ve heard from every MD I’ve spoken to (now in the hundreds): they believe that they are excellent arbiters of quality and decision making, and that the system should let them practice without any restrictions or guidance at all. The problem here is that every individual physician can’t be right, because the aggregate data shows we have a quality and cost problem, to say nothing of medical errors (http://www.bmj.com/content/353/bmj.i2139), opioid over-prescribing, and more. We will *not* solve the cost and quality problems in our health care system by only focusing on doctors–I agree that pharmaceutical costs and “non-profit” hospitals are huge contributors to the problem. But we also won’t get there by demanding that we return to the old fee-for-service system, or by mandating some kind of rationing of care.

  24. Barry,
    It seems pretty clear how the ACO model would have saved money in your case: your cardiologist may have become very reluctant to recommend “expensive high tech interventions” as too risky and therefore not indicated. A downside of the ACO model is that patients may start to become suspicious of the docs….why aren’t they letting me have the extra mri or the expensive cardiology intervention or hip replacement?

    I am all for ACOs as long as patients have a choice of joining an ACO or stay in a traditional medical delivery model….but I am concerned because our policy experts are prone to heavy handed incentives and punishments and mandates to get their way even with unproven programs.

  25. You said: “health care cost increases from 2009 – 2013 were flat compared to GDP rise in that same time span. You are reading that right – health care costs stayed right around 17% of GDP in the current fee for service construct for four years.” Correct!…and the reason likely is the private sector massively moved to provide employees high deductible plans linked to Health Savings Accounts….though it seems our policy experts are reluctant to remember this.

    No less than the Rand Corporation confirms that high deductible plans linked to Health Savings accounts stabilize medical costs: place patients in the drivers seat and when patients share in the savings of prudent use the cost trends stabilize.

    The Rand study says preventive care usage went down too….and that may be bad in the long term. But this side effect can be addressed simply by education and incentives not to forgo preventive care…..although Hadler and others have pointed out there is much folly (and limited science) in current recommendations for preventive care.

    Here is a link to the Rand press release (you can easily find the full study too):

  26. My son, who lives in suburban Chicago, has a 94 year old neighbor who postponed an upcoming birthday party because he is getting a hip replaced. Do 94 year old people get hip replacements in Western Europe, Canada, Japan and Australia at taxpayer expense? American patients want what they want when they want it and they expect someone else to pay for it. In the meantime, doctors have to order a lot of tests they think are probably unnecessary but they have to protect themselves from potential lawsuits and meet the revenue expectations of hospitals that more and more of them are employed by. I think we patients have met the enemy and it’s us.

    As a cardiac patient myself, I rely on my cardiologist to keep me going primarily through medication management but I’ve needed three expensive high tech interventions going back to 1999. I can’t see how the ACO model would have saved any money in my particular case if I were in one for the last 16 years.