I don't know how many of you have heard the new buzz about ACO's -
accountable cost organizations. If you have been following discussions
about Massachusetts health care you have seen this suggested.
ACOs are groups of doctors that receive a fixed amount of money and then
provide all of a patient's health care needs. I guess they figure they
can glue together a pediatrician, a heart surgeon, a dermatologist, etc
and make a cohesive group that provides one-stop shopping for all health
care needs. If the patient needs an MRI, the ACO pays for it. Hip
replacement, same thing. Labs, xrays, the whole deal. Kind of like an
insurance company, except now the doctors are the insurance company
without having any insurance company experience. We take in fixed
premiums and pay out benefits.
Does this sound like back to the future?This is basically capitation
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
for everybody but doctors) they can control costs this way. After all,
you'll think twice before you rip out that kid's tonsils if you have to
pay for it. Considering deliberately mismanaging someone's diabetes so
you can get $50,000 for a BKA? Not if it comes out of your own hide.
I think it will succeed, because if you stop paying people to "do
things" they will pretty much stop doing things. In my specialty the
general goal for most of us is to get a patient's pain under control
with minimal reliance on pain meds. Some of these modalities are
expensive. A spinal cord stimulator lead costs $1500, and the battery
about 10x that. An intrathecal pump is about $10,000. These are hardware
prices. they don't include O.R., anesthesia, etc.
So here I am in my new ACO office and a patient comes in with horrible
pain from failed back surgery that has been refractory to just about
* I know a stim could potentially help a lot.
* However, I also know that if I go around putting $15-20,000 worth of
hardware into people my partners are not going to be happy.
* I also know that writing a prescription is far easier and much better
for my health than spending an hour in front of a c-arm wearing a lead
apron under hot lights. And I will make MORE money that way. Plus, you can't surf the Internet while scrubbed.
So what's going to happen? They gave me an incentive to not do things
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
some Phenergan for you. No wait -- that might drop your WBC. That means
paying for lab tests. Try some flat ginger ale. That's what my mother
gave me for a tummy ache. Excuse me, time to check my email.
This didn't work when it was called capitation. I don't see how it will
work this time, and I can't imagine how they plan to get doctors to join
into diversified groups without killing each other. Maybe it will be
assigned seating like high school. Maybe they have figured out how to
herd cats. Maybe the CIA has secret pheromones that will make us
cooperate like ants and bees.
I want to know what will happen when a patient hates the group's
endocrinologist and wants to go "out-of-ACO". Can you do that, or do you
send the doctor and the patient to counseling to work it out? What if
the cardiologist you want is in another group?
What if you are a very popular or famous doctor, in big demand? Can you
threaten to go to another ACO if they don't give you more money? Will
there be a draft for doctors coming out of residency? When can you
become a free agent?
The ACO's are also supposed to help "coordinate care". This is the new
buzz word. The old buzz word, "preventive care", turned out to be not so
good after the data showed that it actually costs more to do tests on asymptomatic people. Not to mention that a PAP smear or colonoscopy is not preventive so much as early detection. Smallpox vaccine is preventive. Tetanus shots are preventive. Colonoscopies find what's already there. Anyway, it's not like we have any control over whether or not you eat a large pepperoni pizza every night, washed down with a 6-pack of beer, and then a few relaxing smokes. Nor can we prevent gallstones, broken ankles, cerebral aneurysms
or about 99% of the things that afflict people even if they all live like Dean Ornish in an isolation bubble. Healthy diet, a good night's sleep, exercise, don't smoke, watch your weight, and get lung cancer like non-smoker-vegetarian-yoga-enthusiast-transcendental-meditation-teacher-and-successful-actor/comedian Andy Kaufman, dead at age 35.
Do they think this will be like Boston Legal, where all the partners sit
around a conference table and discuss each case? How many of us call our
colleagues after every visit to discuss the patient? "I'm sorry, Dr.
Futznagle can't come to the phone to discuss Mrs. Balderdash. He's
already on the phone talking to Dr. Squigglemeyer and then he has to
return a call from Dr. Fussypants. Can he call you back next week after
he finishes returning last week's calls?"
Even the Europeans aren't that stupid. To really screw things up you
need the United States Congress, which seems to think that reinventing
the wheel by making a square wheel with a broken axle is the way to
decrease gas consumption.
Yes indeed, that's one way to do it.