Not the be-all, end-all

ACOs are a start, but in­sur­ers, hos­pi­tals, pa­tients all must do their part too

Modern Healthcare - - Opinions Commentary - Ge­orge Hu­ber

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.

Ge­orge Hu­ber is as­so­ciate dean for pub­lic pol­icy at the Univer­sity of Pitts­burgh Grad­u­ate School of Pub­lic Health.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.