Not the be-all, end-all
ACOs are a start, but insurers, hospitals, patients all must do their part too
Having read the proposed accountable care organization regulations, it appears that the CMS is heroically trying to address major shortfalls in the American healthcare provider system by emphasizing effectiveness in terms of quality and outcome measures, and efficiency in terms of cost reduction and best practices. Central to this effort is the attempt to incentivize the integration of care for Medicare patients by primary-care physicians and, to a much lesser extent, by hospitals or other healthcare providers.
There is very little in the regulations about hospitals. They can be members and participants of an ACO but “not in control,” and there is little if any specification of their role as is the similar situation for specialists, inter-professionalism, the medical home and disadvantaged populations (save for inclusion of federally qualified and rural health centers as participants). So this effort is broadly and almost universally concentrating on primary-care doctors directing and, inferentially, controlling care.
In addition to uncharted and risky legal, tax and financial hurdles that ACOs need to navigate, there are entrenched provider and patient issues with which they must reckon. American healthcare has been practiced and reimbursed traditionally on a silo basis. Feefor-service and DRG reimbursement methods are closely related to the cost of specialty resources and procedures. Unfortunately, there are no real incentives for specialists to collaborate across specialty lines, including those of primary care.
Primary-care physicians of ACOs will have real challenges overcoming these deeply embedded systemic obstacles. This becomes an even more difficult task when the Medicare beneficiaries assigned by the CMS to an ACO have the freedom to go to any other provider they choose, including those outside of the ACO network. Nor does the assigned patient need to share their medical records among other ACO network providers. Moreover, ACOs are prohibited from advertising for Medicare beneficiaries, even if the number of assigned Medicare beneficiaries is in jeopardy of going below the threshold of 5,000.
And lastly, the primary-care physicians of ACOs also are expected to exercise gentle hands in being patient case coordinators, assurers, referrers, advocates, educators, preventers, enforcers, monitors, motivators and stewards of
The most important variable in the healthcare system might be an educated and informed citizen.
public health. These are high expectations. The proposed regulations and policies are focused only on Medicare beneficiaries with the hope that there might eventually be spillover to other categories of government and commercially insured patients, for which there are currently no laws or regulations or policies protecting ACOs. These also are additional roles where physicians and hospitals have not had much formal education, training or experience.
At least it is a start in recognizing the problems and attempting to address them from the healthcare provider side of this multivariable equation. Insurers of healthcare, for example, should be more than just the financiers of healthcare services. They should also assist ACO providers in the new roles that they are expected to assume.
And how about the patient? Does he or she have any responsibility other than paying taxes and insurance premiums, and maybe showing up to be taken care of and be educated by an ACO physician? To what extent should the patient be expected to understand what ACOs are all about before deciding whether to cooperate?
One could logically argue that the most important variable in the American healthcare system equation is an educated and informed citizen, a process that ideally begins long before their entry into the healthcare system, or entry by someone for whom they are responsible or concerned. We know that reading, writing, arithmetic and thinking are the bulwarks of education in the U.S. Why not add knowledge of personal health and the American healthcare system? What could be any more important in life than understanding how to care for self and others throughout life?
Such literacy, if begun and required from grade one through college, would be most useful to politicians, regulators, clinicians, insurers and citizens themselves as patients and caregivers to those they love—a child, spouse or parent. Although this is a long-term variable that involves cultural change and will span many political careers, there is an urgency that it begin today.
Educators will argue that students already get physical hygiene education and learn about unhealthy habits and lifestyles. But what do they know about illness, disease, chronicity, healthcare professionals, providers, economics, insurance, the elderly, the right questions, who to ask, where to start and so on, until they are actually confronted with a problem and are required to learn as they go.
Educators will argue that these topics will place an additional unwelcomed financial burden on education in preparation and teaching. Perhaps they are topics that could be creatively integrated into the readings, problem solving and exercises of existing curriculums.
So, is the ACO the answer? Not entirely. It is, perhaps, a new approach in helping to better define the problem nationally and in helping to identify other long-term solutions. Past approaches, whether for healthcare research, the provision of healthcare services or healthcare basic individual education, are scattered at best. Organized and cumulative knowledge and literacy about healthcare seems to be a way of bringing it all together for better understanding and a better, more rational healthcare future.