By John Ballard
Last week I heard it again. One of my clients had to "pick up the CD" on the way to his appointment. My wife went through the same foolishness when she had a surgical procedure a couple years ago. I am so ready for medical technology to catch up with the rest of technology. We can transmit images, even videos, from a portable phone to Facebook and yet the patient or some family member is expected to schedule the time, parking and other arrangements to personally pick up a CD with an x-ray or other information from one office (typically imaging) and personally deliver it to the place where the information is needed (surgeon or primary care doctor).
There are complicated reasons for the scrappy, confused, expensive mess passing for health care in America. Much of how the system grew is rooted in the price controls of WWII. When the original Blue Cross and Blue Shield models were first put together they met with stern resistance from doctors simply protecting their turf. They needed hospitals but didn't want them competing for medical services. Consequently all hospitals were non-profit organizations until the Sixties.This is not the place to trace the history of medicine in America but for the interested reader two books are essential reading. Paul Starr's The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry and Maggie Mahar's Money-Driven Medicine: The Real Reason Health Care Costs So Much are the two which I have followed throughout the health care reform debate. The first is fairly dry reading but both are solid pieces of work. Highly recommended.
Accountable Care Organizations are not a new idea but since they don't follow the fee-for-service model they have not bee popular in the medical-industrial complex. There remains plenty of opposition to the concept and I am not optimistic the model will take hold in a meaningful way in my lifetime. But thanks to measures now in place with the Affordable Care Act providers will slowly but surely move to a delivery system which has proved to be less costly than fee for service and at the same time getting better outcomes.
This is from a Health Policy Brief at Health Affairs Magazine.
The health care reform legislation enacted in March 2010 authorizes the Medicare program to contract with accountable care organizations (ACOs). These are networks of physicians and other providers that could work together to improve the quality of health care services and reduce costs for a defined patient population. This brief describes the ACO concept as set forth in the new legislation, discusses how ACOs might evolve over time, and reviews the challenges and opportunities facing health systems, physicians, administrators, insurers, patients, and policy makers as ACOs take shape.
Most public programs and private insurance plans pay for health care on a fee-for-service basis. This means that individual doctors, hospitals, and other providers are paid for each service they furnish to a patient. Critics of this system have long contended that it creates incentives for providers to furnish or order more services. And different providers who see the same patient often fail to coordinate their activities, leading to duplicative or conflicting treatments.
Over the years, there have been many efforts to promote integrated care systems, in which primary care physicians, specialists, and hospitals would work together to manage the overall care of their patients. Commonly cited prototypes include the Kaiser Permanente health plans, Mayo Clinic, and Cleveland Clinic. These systems own hospitals and employ salaried physicians. Their centralized organization means that providers within the systems can work together to improve quality and efficiency--for example, by exchanging patient information or developing and adhering to practice guidelines.
Coordinated Care: The same level of coordination has proved difficult to achieve when doctors and hospitals operate independently. Beginning in the 1970s, some physician groups or joint ventures between physicians and hospitals tried to operate as health insurers on their own. More often they contracted with health insurers to provide total care to an enrolled population. Many of these arrangements involved so-called capitation payment schemes: in return for a fixed monthly payment for each enrollee, the contracting group would accept financial liability for a range of covered services.
In effect, a "capitated group" took over the functions of an insurer, deciding which providers patients could see and what services would be furnished. The hope was that the group would find the best of way of managing care without going above a fixed financial ceiling. Although these arrangements still exist in some places, many consumers resisted network arrangements that restricted their choice of providers. There were also concerns that capitation would replace incentives to provide too many services with incentives to deny care.
The ACO has emerged over the last few years as a way of promoting integration while avoiding some of the perceived problems of past efforts. The concept began with the observations that physicians who are tied to a particular hospital often already function as a sort of informal network, and that their patients tend to stay within the network for most of their care. These facts suggested that groups consisting of one or more hospitals and doctors who use the hospitals, but aren't necessarily employed there, might be brought together in organized systems. Public and private payers could then hold these systems accountable by assessing whether they provided high-quality care to their usual patient population while reducing the unnecessary use of resources. Organizations that took steps to improve their performance would be financially rewarded; this would encourage further steps to improve care management, leading to further rewards and a steady evolution toward fully coordinated care systems.
The reader can already see resistance, on the part of both patients and providers. As patients we have been led to imagine that we are entitled to go anywhere we want for our medical care. The stinging experiences of HMO's still smart for those who recall how the concept was clumsily applied when first introduced.
Surprise!
Insurance companies are in it for the profits.
And the fee for service model is guaranteed to make doctors plenty of money. The more you treat the more you make.
Same applies to the drug companies. The more you sell the better your financial performance.
Hopefully the medical community has more professional motives. There is a big difference between professional compensation and corporate profits.
More details at the link. But the main point is that Medicare will become the driving force behind the formation and promotion of ACO's. Reimbursement rate differences lie at the heart of the changes.
The health reform law establishes a Medicare shared savings program for ACOs, to take effect no later than January 2012. This is not a demonstration or pilot project; the law makes contracts with ACOs a permanent option under Medicare. However, many of the specifics are left to the discretion of the secretary of the Department of Health and Human Services (HHS), which will allow the design of the program to evolve over time.
As I said earlier, I don't expect to see the flowering of ACO's any time soon. But you can be sure I will do my part as an informed patient to drag whatever doctors I need in that direction.
More people are in denial about the accelerating costs of health care (health care inflation -- not the same as across the board cost of living inflation) than about climate change. We haven't any choice about getting costs under control.
Unless health care costs are brought under control, the collapse of our expensive lifestyle will make the housing bubble look like a blip on the screen. Accountable Care Organizations are but one component of the changes we need.
No comments:
Post a Comment