January 14th, 2011
Editor’s Note: In the post below, Caroline Poplin takes a skeptical look at Accountable Care Organizations (ACOs) and the trends they represent. For more on ACOs from various perspectives, readers can consult the January issue of Health Affairs, released on Thursday, January 6, titled “Accountable Care Organizations: Making Them Work.”
Physicians have doubtless been issuing jeremiads since before Jeremiah. We are overworked, underpaid, and underappreciated.
But today, general internists have a real problem. And it is our leaders who do this to us. As summarized in the Annals of Internal Medicine:
To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups. The most successful physicians will be those who collaborate with other providers to improve outcomes, care productivity and patient experience.
In the future envisioned by the health policy community, including the leadership of the Amercian College of Physicians and the American Medical Association, patients who want a personal physician, someone they know and trust, who understands and cares about them as individuals will have to pay extra for “concierge” care. Everyone else will migrate to team care from large “Accountable Care Oranizations” (accountable to whom, one may ask—certainly not the patients). These teams may well improve patients’ blood pressures, glucose control, lipid panels, maybe even weight, and indeed improve the outcomes of patients whose outcomes can be improved. Their care will be efficient: providers (yes, providers) who do not see enough patients, whose patients do not improve adequately, who order too many tests, do not meet the fifteen criteria for meaningful use of EHRs, or do not continuously pursue quality improvement projects, will see their incomes fall.
Perhaps the new organizations will provide better care for some patients and some conditions. Will other patients — those with poor prognoses, bad attitudes, complex or ill-defined diagnoses, multiple complications, cognitive limitations, even just morbid obesity — be lost in the shuffle.
And whether this radical overhaul of the health care delivery system will reduce health care costs overall, ostensibly the point of the exercise, is unknown. The cost of multiple layers of highly paid managers (including multi-million dollar executives) and the extensive information technology infrastructure on which these elaborate systems depend, is not trivial. Indeed, modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions that pay serious attention to suggestions from production workers and those who deal directly with customers. What little evidence we have on cost savings from ACOs is largely anecdotal and equivocal.
I am a Board-certified general internist. I worked for many years for just such an Accountable Care Organization. It was factory work: we were interchangeable cogs in a vast machine. The people who saw patients, especially “primary care providers” like me, were at the base of the pyramid and the bottom of the pecking order.
The future is clear. The management of the ACO — professional administrators, and physicians who see few if any patients — will schedule every moment of every primary provider’s day, critique every decision, continually scrutinize and evaluate every aspect of one’s practice. At my ACO, yes, we were on teams, but given no time to communicate with one another. We were forced to complete clunky electronic records we had no time to read. Despite years of training and experience, we had no input to the system that controlled our lives. We were not respected as professionals. It was demoralizing.
If one is concerned about a “shift work” mentality in medicine, surely it develops not in residents who get more sleep, but in physicians who can only survive by meeting ever-higher “performance goals” set by others.
So far, specialists seem to have largely escaped these problems. There seem to be fewer performance measures for them, less pressure to adopt “meaningful use” of electronic health records, less concern about supervision and efficiency. The community still respects them.
Is it any wonder that medical students and residents are signing up for specialties, voting with their feet?
Contrasting The United States And Europe
What has baffled me throughout this process is the logic of the reformers, physicians and non-physicians alike.
After all, the European countries, including those that are avowedly socialist, have achieved better outcomes than we, at far lower cost, with conventional, decentralized delivery systems and fee-for-service-type payment practices. Yes, many have electronic medical records, but I understand that European systems are primarily designed to provide a doctor with information about her patient, not “feedback” about her performance.
In Europe, some 50 percent of physicians practice primary care. Here, 70 percent of physicians are specialists, and, given the situation, we can only expect that number to climb.
The Cost Drivers: Insurers And Technology
Everyone agrees that the biggest problem in American health care today is its outsized accelerating cost, already 17 percent of GDP despite the fact that many uninsured people receive no care at all.
From my vantage point, the two principal drivers of cost in our system are the insurance industry and excessive expensive technology. The insurance industry – which will no longer be allowed to manage risk — cannot manage care, and manages cost by requiring discounts from providers, which the companies pocket. We should pay insurers for processing claims, period.
Also, we have disproportionate incentives in our system for ever-costlier technology, particularly specialty procedures requiring high-tech equipment, as well as expensive imaging, tests and pharmaceuticals. Yes, there is competition, but rarely on price, since manufacturers are reimbursed for whatever they charge.
Nevertheless, health care reformers have largely ignored insurers and manufacturers, trusting, without much evidence, to future market competition. Instead, the policy elite has targeted primary care. They believe it is poor. We do not work hard enough to keep our patients healthy, we neglect important preventive measures, and our patients therefore develop costly avoidable illnesses and require too many expensive hospital admissions. We do not coordinate with others.
Misdiagnosing The Ills Of Primary Care By Ignoring Internists
Fair enough, perhaps. What is troublesome is that the reformers never think to ask why primary care in this country isn’t better. Certainly they never ask us.
The health policy elite appears to have concluded that the crux of the problem is primary care practitioners, internists included, who are largely ignorant, lazy, and indifferent to their patients’ welfare, and oppose change of any kind. We do not know or care that a diabetic’s hemoglobin A1C should be below 7.
Therefore, we need tight supervision, complex systems of financial incentives and penalties, and frequent “feedback” about our deficiencies. We need electronic records to remind us that our female patients are due for mammograms, that we should advise smokers to quit. And we must reach our goals efficiently, using the minimum number of those expensive tests, and managing large panels of patients. (So we can’t spend much time with anyone.)
The experts decry traditional fee-for-service. And there is no question that fee-for-service encourages development and overuse of expensive procedures, such as frequent endoscopies to follow Barrett’s esophagus, or CT angiography to screen for coronary artery disease (no evidence basis for either). But instead, policymakers are concerned about excess office visits.
Therefore, our fees are to be “bundled” with the hospital and the ACO. You can imagine, after the hospital has taken its share — for services it performed or money it “saved” — and senior management has helped itself, what will be left for the providers who actually see the patients.
In part, internists have done this to themselves. Back in the day, there was no “primary care.” There were general practitioners, who treated routine medical problems, and there were internists, who followed adults with more complex conditions.
As the expansion of medical knowledge accelerated in the last thirty years or so, no individual physician could keep up with it all. Multiple problems had to be handled by multiple specialists. At the same time, fees for evaluation and management, the bread and butter of general internal medicine, fell, partly because small practices had no leverage against large insurance companies. To make a living, a practicing internist had to step up her volume, seeing twenty, thirty patients or more a day. It is daunting, sometimes even dangerous, to try to deal with complex issues or multiple chronic conditions in ten minutes.
In the meantime, general practitioners were disappearing. So internists picked up their work: routine physicals, minor acute complaints, and isolated chronic problems — uncomplicated hypertension, for instance –easier to deal with in ten minutes. We became “primary care physicians.”
But one doesn’t need seven years of medical training for this sort of practice: less expensive mid-level professionals — nurse practitioners and physician’s assistants — can provide it just as well. This new competition increased downward pressure on fees, and turned us into “primary care providers” suitable to staff the bottom rung of the ACO. Many general internists outside the hospital are not practicing at the top of their capacity, but nearer the bottom.
The current fee structure in our fee-for-service system is designed for the medicine of the 1950’s, when most illnesses and injuries were discrete and acute. Single acute conditions (the “chief complaint”) that present with many symptoms and physical findings generate maximum fees. The more elaborate the history and physical, the more one is paid: these two elements account for two thirds of the fee. Everything else — reviewing glucose records, specialists’ reports, developing a differential diagnosis, reviewing alternative treatments, and treating conditions beyond the “chief complaint” — accounts for just one third.
Following Medicare, payers pay little or nothing for anything done outside the visit. Doctors are supposed to make telephone calls, respond to emails, review records, consult with specialists, visiting nurses and family—all for free. Is it any wonder our system is not coordinated?
The Proper Role Of Internists In The Health System
Internists are not Luddites. We understand that American health care has become increasingly dysfunctional as medicine has advanced. We appreciate that midlevel professionals and specialists are indispensable to the care of modern complex patients, and that electronic health records can be invaluable if they provide us with convenient, real-time, comprehensive information on our patients. It should be the internist’s job to coordinate care, not by ensuring that patients get their colonoscopies, but by integrating the information provided by our midlevel colleagues, specialists and tests, in order to help our patients understand problems and tradeoffs and make decisions on treatment, as internists in the hospital (so-called “hospitalists”) do.
We welcome assistance. But we should not be forced to surrender our autonomy to ACOs. We know what our patients need: we don’t need highly compensated management to tell us. Doctors would happily adopt electronic records (particularly if they were cheap and interoperable) if we thought they could help us take care of patients. Clearly, the profession, which in general embraces high technology, doesn’t find the current EHRs (largely designed to gather information about the physician performance and statistics for research) useful; that is why the government had to define and mandate “meaningful use”.
There is a vital role for the general internist in modern medicine, but it is not on a virtual assembly line at the bottom of an ACO. Better electronic information systems and a fee structure suited to modern medicine, one which pays more for what we do with our heads (even when the patient is not present), less for what we do with our hands, that pays a provider more for treating more complex patients, could go a long way towards improving co-ordination and reducing cost without disrupting the entire delivery system.
It is also worth remembering that the last time Americans saw managed care—for an ACO is an HMO by another name–in the 1990s, they resoundingly rejected it.
Internists are professionals. We want the best for our patients. We have much to offer, but we expect respect. The policy elite can either do things with us, or to us. So far they have chosen the latter.
Despite the most strenuous prevention measures, there will always be sick patients. And there will always be doctors. But outside of the hospital, the American general internist may go the way of the general practitioner before him: the medical world of the future may consist of midlevel professionals, and specialty physicians. Maybe this care will be cheaper and better — or not. We will see.Email This Post Print This Post
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