THCB

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:

Livongo’s Post Ad Banner 728*90

Categories: THCB

28
Leave a Reply

7 Comment threads
21 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
11 Comment authors
Xinyaanish_kokaPesto SauceAllanSteven Findlay Recent comment authors
newest oldest most voted
Xinya
Member

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

Pesto Sauce
Member
Pesto Sauce

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… Read more »

anish_koka
Editor

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… Read more »

Pesto Sauce
Member
Pesto Sauce

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… Read more »

Steven Findlay
Member
Steven Findlay

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… Read more »

meltoots
Member
meltoots

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… Read more »

Pesto Sauce
Member
Pesto Sauce

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.

Lisa Bari
Member
Lisa Bari

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… Read more »

Lisa Bari
Member
Lisa Bari

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… Read more »

anishkoka
Member

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… Read more »

anishkoka
Member

And don’t even get me started on medical errors. See this: https://thehealthcareblog.com/blog/2015/11/30/very-bad-numbers/

I can’t even find the bmj ‘study’ seems more like an analysis?

Pesto Sauce
Member
Pesto Sauce

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

meltoots
Member
meltoots

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… Read more »

Barry Carol
Member
Barry Carol

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… Read more »

meltoots
Member
meltoots

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… Read more »

Pesto Sauce
Member
Pesto Sauce

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… Read more »

Lisa Bari
Member
Lisa Bari

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… Read more »

meltoots
Member
meltoots

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… Read more »

Pesto Sauce
Member
Pesto Sauce

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,… Read more »

Paul @ Pivot ConsultingLLC
Member

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… Read more »

Barry Carol
Member
Barry Carol

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.

William Palmer MD
Member
William Palmer MD

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.

anishkoka
Member

For the picture at the end that’s cutoff.. https://anishkoka.wordpress.com/2016/05/04/637/
Thanks to @EJSMD for tweeting.

Barry Carol
Member
Barry Carol

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… Read more »

Paul @ Pivot ConsultingLLC
Member

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… Read more »

Barry Carol
Member
Barry Carol

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.

Allan
Member
Allan

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.

Barry Carol
Member
Barry Carol

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,… Read more »