Here is a short update on a post I put up about a month ago about CMS’ proposed regulations for setting up Accountable Care Organizations. The ACO proposal calls for shared savings and other incentives for providers, with a transition after a few years to a real risk contract. But Congress put a “poison pill” into the concept because it was afraid to limit customer choice. At the heart of my argument was this point: “How can you be held accountable, as a provider group, if you cannot control the management of care of your patients?”
The latest news, according to my sources, is that even the most advanced ACO-like organizations like Geisinger and Mayo are not interested in signing on to this proposition. The financial risks can come crashing down quickly and are just too great.
In a recent Boston Globe interview, consultant Marc Bard explains how it would have to work for providers to agree to share risk in an ACO network:
Q. Some consumers fear they won’t be able to go to the doctors or specialists they want in the new system. Is that a legitimate fear?
A. The answer is of course. We can’t be spending 17.5 percent of our gross national product on health care and allow everybody to broker his or her own health care. So ultimately there are going to have to be trade-offs made. The public’s going to have to make them. The delivery systems are going to have to make them. Absolutely there are going to be limitations.
Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and
front-line driven process improvement at Not Running a Hospital.
The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:
I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?
We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt’s life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.Continue reading…
After being part of a discussion at the Institute for Healthcare Improvement today, I have decided to change my profile, above, from this:
Advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.
Advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.
What I am suggesting is that clinicians should do their best to collaborate with patients to understand their needs and desires and to jointly design plans of care that are as consistent as possible with those needs and desires.Continue reading…
I’m sorry, but I just don’t get it. Last week, CMS announced proposed regulations about setting up Accountable Care Organizations. Here’s the statutory background and the theory of the case, as set forth in the March 31 Medicare Fact Sheet:
Section 3022 of the Affordable Care Act, added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012. This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an “Accountable Care Organization (ACO)” that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending. Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.
Here’s the introductory paragraph from the CMS summary:
ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first. Patient and provider participation in an ACO is purely voluntary.
How will this work? And, will it work?
Let’s dig in.Continue reading…
At a recent talk, Dartmouth’s Elliott Fisher facetiously remarked that we cannot yet be sure whether accountable care organizations (ACOs) will actually be accountable, caring, and organized. Well, if some providers have their way, they certainly won’t be accountable.
This story by Jordan Rau in the Washington Post relates comments being made as Medicare writes its rules governing the ACOs. Here are some quotes:
[S]ome prominent doctor and hospital groups are pushing for features that some experts say could undermine the overall goal – improving care while containing costs. They’re seeking limits on how the quality of their care will be judged, along with bonus rules that would make it easier for them to be paid extra for their work and to be paid quickly.
Here’s the one I like best:
The Federation of American Hospitals, representing for-profit facilities, goes further, urging that ACOs be allowed to choose their patients. “Providers are better positioned than CMS to determine which of their patients would be appropriate candidates,” the federation wrote.
So, we are happy to be held accountable, but only if we get to choose which patients are part of our network.
A recent report by the Massachusetts Inspector General raises a thoughtful concern about the implementation of global payments in the state.
In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.
There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.Continue reading…
Some people at the University of Washington and colleagues from around the country run a wonderful website called Tough Talk: Helping Doctors Approach Difficult Conversations. They call it a “toolbox for medical educators” who want to teach about ethics and communication. Topics include:
Common teaching challenges plus tips for recovering from them • Optimizing small group dynamics • Providing effective, honest feedback • Helping clinicians develop and operationalize personal learning goals • Motivating engagement and self-assessment in reluctant participants
Look at this statement of philosophy:
Many argue that ethics and communication cannot be taught. Since these skills lie in the realm of the interpersonal, they do build on skills and practices we begin developing from our earliest interactions. However, evidence shows that practice and experience can lead to development and enhancement of these skills. This human element is where the moral work of medicine happens. We have a responsibility to attend to these skills and work to develop them, even as we strive to perfect our other core clinical skills. Quality patient care depends on it.Continue reading…
I have written several times about the ongoing saga between the state administration and the health care insurers in the state concerning premiums for small businesses and individuals. Over the last several weeks, several insurers have reached settlements with the Division of Insurance. At least one has not and has prevailed at the appeals board because the rates forced upon it by the state were not actuarially sound. Where settlements have been was reached, they were not based on actuarial principles: They was based on a desire to get past this impasse and provide some stability to customers.Continue reading…
Lisa Suennen, a venture capitalist, writes this post about the provision in the national health care reform act that created the Center for Medicare and Medicaid Innovation (CMI). This agency has $10 billion to “research, develop, test and expand innovative payment and service delivery models that will improve the quality and reduce the costs of care” for patients covered by CMS-related programs. Lisa notes, “What is great about CMI is that they have the authority to run their programs much more like a business would without many historical governmental constraints. ”
I don’t want to be a stick in the mud, particularly as my able friend Don Berwick takes charge of CMS, but I want to point out that previous efforts by the government to be innovative in other fields have failed because:
(1) Venture funding embodies risk-taking. Government usually does not do this because there is a political imperative never to be blamed for misspending taxpayer money. The bureaucracy, therefore, systematically eliminates ideas that are untested.Continue reading…