In ACO era, physi­cians will still play a leading—but chang­ing—role

Modern Healthcare - - COMMENT - By David Dra­nove In­ter­ested in sub­mit­ting a Guest Ex­pert op-ed? View guide­lines at mod­ern­health­ Send drafts to As­sis­tant Man­ag­ing Edi­tor David May at dmay@mod­ern­health­

More than 8 mil­lion Amer­i­cans have signed up for health in­sur­ance thanks to the Pa­tient Pro­tec­tion and Af­ford­able Care Act. Sig­nif­i­cantly in­creas­ing ac­cess to care, the 4-year-old health­care re­form law also cre­ates in­cen­tives for providers to re­or­ga­nize the de­liv­ery of health­care.

The ACA has pro­moted the growth of ac­count­able care or­ga­ni­za­tions. Where suc­cess­ful, ACOs have the po­ten­tial to bend the cost curve and im­prove qual­ity. They are tak­ing many forms, with some led by large mul­ti­spe­cialty group prac­tices and oth­ers by ver­ti­cally in­te­grated hospi­tal sys­tems with cadres of em­ployed physi­cians.

Physi­cians will al­ways re­main cen­tral to pa­tient care. Yet the ACA chal­lenges the tra­di­tion­ally, if not fiercely, in­de­pen­dent prac­tice of medicine. The 21stcen­tury physi­cian is in­creas­ingly em­ployed by a large provider or­ga­ni­za­tion with ac­count­abil­ity to man­age­ment, sub­ject to stan­dard­ized treat­ment pro­to­cols and re­quired to in­ter­act with com­plex elec­tronic health records.

Just how physi­cians will trans­form med­i­cal care in this new en­vi­ron­ment en­gen­ders much con­ver­sa­tion, as was re­cently demon­strated at a health­care man­age­ment sym­po­sium held last month at North­west­ern Univer­sity’s Kel­logg School of Man­age­ment on “The Fu­ture of the Physi­cian.”

Health in­dus­try lead­ers of­fered their per­spec­tives on the ACA’s im­pact on the busi­ness of health­care. Among the distin­guished speak­ers, pres­i­den­tial ad­viser Dr. Ezekiel Emanuel pro­vided sev­eral provoca­tive pre­dic­tions, rang­ing from the end of em­ployer-spon­sored health in­sur­ance to the clo­sure of 1,000 hos­pi­tals. Dr. Ardis Dee Hoven, then-pres­i­dent of the Amer­i­can Med­i­cal As­so­ci­a­tion, shared strate­gies physi­cian groups are us­ing to re­duce the eco­nomic and so­cial bur­den of chronic dis­eases.

Here is my take on some con­fer­ence high­lights: In­sur­ance com­pa­nies still serve a pur­pose. In­te­grated health sys­tems have en­tered the in­sur­ance mar­ket­place, leading some to spec­u­late the end of the Blues, Aetna and United-

David Dra­nove is an econ­o­mist and pro­fes­sor of health in­dus­try man­age­ment at the Kel­logg School of Man­age­ment, North­west­ern Univer­sity, Evanston, Ill.

Health­care. How­ever, early at­tempts to pro­vide in­sur­ance and provider ser­vices in one or­ga­ni­za­tion have shown only limited suc­cess. In­sur­ers con­tinue to have the risk pre­dic­tion know-how and data ca­pac­ity to iden­tify best prac­tices to steer pa­tients to­ward cost­ef­fec­tive providers. They aren’t go­ing any­where for now.

ACOs can and do lis­ten to doc­tors. It’s a myth that ACOs are physi­cian con­trol freaks, com­pro­mis­ing pa­tient care to dol­lars and cents. ACOs do of­fer con­trac­tual re­la­tion­ships be­tween var­i­ous par­ties to con­trol costs and im­prove qual­ity. Ideally, they en­cour­age physi­cian par­tic­i­pa­tion in gov­er­nance and work closely with them to de­velop pro­to­cols. ACOs may be a mod­ern-day ver­sion of HMOs, but this time around, they may af­ford bet­ter ac­cess and fewer ad­min­is­tra­tive sna­fus. If they can pro­vide co­or­di­nated qual­ity care and save money in the process—the jury is still out with re­gard to these goals—it will be a win for ev­ery­one in­volved.

Dig­i­tal medicine will drive the cost/qual­ity equa­tion. Physi­cians com­plain that user “un­friendly” EHRs take time away from the pa­tient-physi­cian in­ter­ac­tion—a ma­jor rea­son cited for their in­creas­ing job dis­sat­is­fac­tion. Agreed. EHRs are frus­trat­ing. We are cur­rently in the Wild West here with mul­ti­ple record sys­tems sold by a va­ri­ety of ven­dors whose prod­ucts re­main largely

in­com­pat­i­ble. Yet as a coun­try, we spend close to $3 tril­lion an­nu­ally on health­care with­out much to show in the way of qual­ity. Elec­tronic doc­u­men­ta­tion of­fers a so­lu­tion: it pro­vides the data re­quired to be­gin link­ing the qual­ity of care to the cost of care. EHR sys­tems are evolv­ing. We all need to be pa­tient. We’ll get there be­cause we must.

Only cost-con­scious physi­cians need ap­ply. In the 1970s, tele­vi­sion char­ac­ter Mar­cus Welby, M.D., epit­o­mized the fam­ily doc­tor who did ev­ery­thing that was med­i­cally pos­si­ble for his pa­tients, some­times step­ping out­side of stan­dard prac­tice if he felt it nec­es­sary. Dr. House, an opi­ate ad­dict with a bor­der­line per­son­al­ity dis­or­der, re­placed the beloved Dr. Welby, only to show even less con­cern for costs and stan­dard prac­tice. This model is no longer sus­tain­able.

Physi­cians must own up to the eco­nomic con­se­quences of their de­ci­sions, whether through em­ploy­ment or con­trac­tual mod­els. Physi­cians must also come to ac­cept treat­ment pro­to­cols, how­ever rigid they may ap­pear. We have tol­er­ated wide­spread prac­tice vari­a­tions for too long. And med­i­cal schools must se­ri­ously con­sider a cur­ricu­lum over­haul that teaches physi­cians how to man­age the care-de­liv­ery process.

The fu­ture of physi­cians re­mains se­cure. With the newly in­sured ac­cess­ing care, physi­cians—pri­mary-care spe­cial­ists in par­tic­u­lar—are in high de­mand. The ones who can adapt to a post-ACA world and par­tic­i­pate in the co­or­di­nated de­liv­ery of care will likely thrive. They may even find greater job sat­is­fac­tion, if health­care re­form pro­vi­sions truly re­sult in sav­ing lives and money.

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