Lisa 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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