The ACO Fix

Kip Sullivan posted an op-ed in “The Health Care Blog,” “On the Ethics of Accountable Care Research,” on August 25, 2017.

Mr. Sullivan’s questioning the ethicality of health system generated research papers touting statistically insignificant results as triumphs, while perfectly valid and well-reasoned, is like questioning the validity of a teacher’s grading curve while missing that the class is gaming the system.

A system ginned up in the only policy factory in the country with policy-makers naïve enough to actually believe that hospital systems would actually cannibalize their core business to split the results with CMS, then split a legally mandated two thirds with the doctors, then pay its costs out of the rest, would ever work. Commercial payers do it, too, but for far more practical reasons.

The Accountable Care initiative, far more vulnerable than Obamacare, is being circled as easy prey for elimination by D.C. policy lions and pundits. It is undeserving of this fate for one, single, compelling reason. The program theory is valid and, with the right partners, is thriving as a win-win.

Its advantaged design partnership to exactly the wrong partners is the ill-conceived – and failing – part.

Who are the right partners? Independent physicians, for example. The ones that are focused on providing better value for their patients and are incentivized because the new money in healthcare is in delivering value. The broad delta between a bloated, wasteful, ineffective system and the improved one you create can restore fiscal stability to primary care physicians, who are on the verge of being price-cut out of business. Primary care physicians are the key because they can be very effective, and less costly, clinical managers for a patient’s overall care.

Physician ACOs’, however, are destined to be small and relatively inconsequential because hospital systems have been buying up their potential participants for years. After 45 years in healthcare, mostly hospitals, I know that one quite well. If you’re four times the cost of the competition and can’t control the prescription pad, own the pen to own the market.

So as not to be misunderstood, hospitals have their place. They are essential community assets, and, you need big institutions to do big things.

Prevailing upon them to cannibalize their customer base and revenue stream, risking their long-term survivability on some “do your fair share” ideology, however, clashes with reality so starkly that it begs rationalizing survival in the public interest and acting exactly as hospital leaders have.

Let’s be real. Looking for savings from the people who are responsible for managing health crisis is exactly the wrong place to look.

Looking for savings from the people who are responsible for managing patients’ health is exactly the right place.

That’s why non-hospital affiliated, physician governed, professionally managed ACOs’ consistently and substantially outperform hospitals by managing utilization and site of service based on value and having and taking long term responsibility for their patients. Physicians understand that improving health status – keeping people healthy by preventing and managing chronic disease by slowing, stopping or reversing its progression – is the only way to succeed long term.

That is the fundamental problem not only with the ACO system, but, with the entire governmental concept of healthcare. Healthcare is not paying for services. It is providing them.

In a truly American tradition – put providing that care in the right hands by equipping, enabling and empowering their healthcare representatives – physicians. They are not going to spin and sell. They are just going to get the job done.

The mechanism to do so is both simple and fair. Disqualify ACOs’ that chronically have not or cannot generate statistically meaningful savings in areas that they can and should control to make room for a proven entity to fill the void.

The rest will take care of itself.

James Doulgeris is the CEO of Osler Health


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2 replies »

  1. Thank you, James for a refreshingly clear perspective.

    The zero-sum game between hospitals as administrators and independent physicians as administrators (yes, I know I’m oversimplifying to make a point) has been immensely tilted in the hospital’s favor by the strategic use of health information technology. The HITECH era policies that have put integrated delivery networks (built around hospitals) in control of the referral and analytics are now making quality and cost nearly impossible to measure. Paradoxically, health information technology now presents the single largest barrier to practice innovation or any significant reform.

    Information blocking and the lack of patient-centered longitudinal health records have come to the fore with the massively bipartisan 21st Century Cures Act that could, if the regulators actually have the gumption to follow,through, begin to undo the information oligopolies HITECH created. The comments of the well-organized health records vendors http://www.ehra.org/sites/ehra.org/files/docs/EHR%20Association%20Comments%20on%20ONC%20Trusted%20Exchange%20Framework%20%26%20Common%20Agreement.pdf are a preemptive plea to regulators to ognore 21st C Cures reforms.

    The problem is exacerbated by a combination of fatalism and frustration of physicians. Our colleagues realize they have lost control of the information tools of our profession but they don’t realize how fast technology is actually moving and how costly the lack of agency with respect to technology will be to medicine as a profession.

  2. Meaningful healthcare reform, as in diminished national health spending by >30% and a reduction of our nation’s maternal mortality ratio by >50%, will not occur without a community by community, locally promoted, strategy to ensure the equitable availability of Primary Healthcare for the citizens of every community. A nationally ‘fostered’ financial plan will eventually be required but will be ineffectual without a “shoot the moon” strategy to support the locally identified stakeholders that already exist in every community to assure their local needs.
    As a reminder, the state by state maternal mortality ratios were published for 2005 thru 2014 in the October 2016 issue of the medical journal OBSTETRICS & GYNECOLOGY: “Healthcare Disparity…” The basics still apply. 500 or more citizens die annually with a pregnancy solely because they live in the wrong nation. It remains the most telling attribute that defines the deficiencies in our nation’s healthcare for its availability and accessibility, community by community.