An Old Friend's Newest Challenge: Rein in Massachusetts' Health Costs
An old, dear friend of mine and fellow XLHealth Board member, Stuart Altman, was just appointed chief of healthcare cost containment for Massachusetts' ground-breaking reform effort -- a harbinger of things to come nationally as the Affordable Care Act now hurtles toward implementation. The local NPR affiliate did a great interview with Stu that I wanted to share here. As always, Stu brings tremendous insight and a sense of history and trends to his work, and as goes Massachusetts, so will go the rest of the country in 2014 and beyond.
"Massachusetts is the first state to say that health care costs must stop increasing faster than that of most other goods and services. Prof. Stuart Altman, a Brandeis economist who advised President Richard Nixon on health policy and President Bill Clinton on Medicare, has responsibility for helping the state achieve that goal.
Gov. Deval Patrick recently named Altman to chair the Health Policy Commission, the new board overseeing the sweeping cost-control law. The board, whose other members were announced last week, will monitor progress toward keeping health care spending in line with state economic growth overall. While he's "hopeful" the state can meet this goal, Altman notes that many attempts have failed over the years. WBUR's Martha Bebinger spoke with Altman about the challenge. Here is an edited transcript of that interview:
How do you see this new role?
Massachusetts has put together the best kind of balanced program that I could think of in the country, where it is relying at one level on the many changes that are going on in the private sector. But it also has put together an overarching public assessment of what's going on to make sure that it works, and it actually brings cost down without hurting quality.
If the changes that are currently in place don't do that, this commission is responsible for giving an early warning sign. So we don't have direct regulatory power to force the system to change, but we do have a monitoring role to make sure that it is working. If it's not, [we would] first direct the delivery system and the payers to change, and if that doesn't work, we could also recommend back to the legislature that the state needs more authority.
On one level I'm pretty optimistic. The level of changes that are occurring in the state are really very substantial. And I would say that the delivery systems, including our very big delivery systems, they really are seriously trying to restructure to live within a tighter budget than they had in the past. And the payers too -- Blue Cross, Tufts and Harvard also -- are tightening up the reins and not giving big increases.
But I've been around a long time and I've seen other years and other decades when after a while the cost-containment mechanisms in place began to fall apart, and did fall apart. So while I'm going into this quite optimistic, I also have a degree of skepticism so I'm going to be watching it pretty closely.
You have seen interest in reining in costs wax and wane. How do you rank this period?
If we look back in history we had very strong government regulation environment in the early and middle 1970s, actually put forward by a Republican administration. It looked like the government was going to be a very strong regulator of growing health care spending. We had wage and price controls from '71 to '74. We created health planning agencies all over the country. We had tough certificate-of-need laws.
And then as we move through the '70s we gradually dismantled it all and by the end of the '70s, it was all gone. Then we had a very brief period when the providers had what we called a "voluntary effort" to control their spending. All that fell apart and we had the biggest growth in our history in the 1980s.
Then we introduced managed care, which was extremely effective in slowing the growth in spending, but it was perceived by the patients — and the beneficiaries and the press — as a system that was holding back access and quality. We had this strong backlash and we essentially destroyed managed care by the end of the ‘90s. So I've seen both the private sector fall apart and the government sector fall apart.
Now, I think what's being done is smarter, and not quite as aggressive as the ‘90s, which I think is a good thing. If you're too aggressive you're going to get a lot of backlash too quickly. So I give it a higher probability of success than either the ‘90s or the ‘70s, and I am hopeful.
What's your main worry?
There are two:
Ultimately the constraints begin to hurt certain segments of the provider community, [and they] begin to put out statements to the patients that they're being denied needed care and we begin to develop a new backlash. So I think patients need to be part of this equation and we need to be balancing their needs with the people that pay the bills, so that's one side.
Massachusetts can only be so far ahead of the rest of the country. If inflation really begins to rear its head again in the rest of the country, the likelihood that Massachusetts would be able to really have a significantly lower level of spending growth is hard to hold on to. I'm going to be very conscious of trying to minimize any backlash and I'll also be watching what's going on in the rest of the country.
For patients, are things moving along now in terms of communicating clearly with patients as you think they should?
No. I don't think patients really understand these limited networks and tiered networks and ACOs and the like. I think there needs to be an expanded consumer education program. Also I think we need to do it smarter. You don't force a patient into any one delivery system, you just make it more expensive if they jump out of one to the other, which continues to gives them the choice. What happened in the ‘90s is that often they had no choice, they had to be at a particular network and they couldn't jump out.
So I think we've learned something in the last 20 years. If we're going to ask organizations to have responsibility for total spending of a particular patient population, [the patients] need to know they're in a particular group, but they also need to have the flexibility if for some reason they want to get out. I think we need to better educate our consumers and patients, but I think we've also learned from the ‘90s, so I'm hopeful.
This story is part of a reporting partnership that includes WBUR, NPR and Kaiser Health News.
Election Gives Health Reform the Kiss of Life
It's hard to argue this wasn't a decisive victory for the President and Democrats in the Senate. What remains to be seen is whether intractable Congressional Republicans will come to the table to get stuff done.
While it was a distant #2 issue in exit polls, this election was a de facto referendum on health reform. The ACA will not be repealed and is now assured to be Obama's lasting legacy. The "repeal and replace" campaign -- over three dozen repeal attempts in Obama's first term at taxpayer expense of more than $50 million -- is over. The GOP fought the ACA fiercely but I expect it will be hugely popular by 2016. Our hope is that Congressional Republicans will lay down their arms and help shape the ACA's implementation so they can share the credit when it's as successful as Medicare Part D has been. House Speaker John Boehner made some welcome gestures this week, asserting that "ObamaCare is the law of the land" and that the repeal agenda is over. We'll see.
Here are some thoughts on what happens in government health programs now that the election is over:
Sequestration and Fiscal Cliff: the 2% across-the-board sequester will not happen and the two parties will make a deal on the fiscal cliff that leaves everyone pissed — like compromise is supposed to. The political dynamics strongly favor the President, as his ideal scenario — raising taxes on the wealthy to accompany budget cuts -- occurs without any legislative action, and nothing happening in Congress is always a safe bet these days. Any deal reached will now involve both entitlement cuts and tax increases, we'd guess in the neighborhood of $2T or roughly half that recommended by the Simpson-Bowles Commission, and it will have bipartisan support.
"Doc Fix": The Sustainable Growth Rate (SGR) or the "doc cut" will be fixed, but it has to be paid for — and that's the obstacle both parties struggle with. MA rates are profoundly impacted by this issue, and Congress's inclination to deal with it through annual increments rather than the 10-year price tag in CBO estimates means that MA plans must wait until the next year's rates are announced. The discrepancy between how and when MA rates are set vs. FFS means that MA plans are never really made whole. It's a tremendous challenge for our industry — and an enormous windfall for MA in 2014 and beyond if Congress solves the problem.
Exchanges: Many Red State governors held out hope the election would settle whether they must prepare for health reform. The 11th hour means most have been caught flat-footed and the Federal Exchange will operate in over 30 states and will be the defining marketplace for health insurance starting in 2014. Far-right governors in Kansas and Virginia will eat the Federal fallback; Wisconsin Governor Scott Walker is now scrambling to get his own exchange together, and a handful of others may follow. It's one of the supreme ironies of Obama's reelection: the governors who screamed loudest of a "government takeover of health care" are about to get just that for their inaction, when the Federal Exchange comes to town in 2014.
Medicaid: most, if not all, of the 7-8 Red States who opposed expansion following the Supreme Court ruling will fold and take the expansion funds in the next 90 days — it's just too good a deal to pass up. Most of the 16 Million new Medicaid beneficiaries envisioned by the ACA — many childless uninsured adults -- will be assured of coverage in a second Obama term.
Dual Eligibles: The migration of dual eligibles to health plans will now move forward in more than two dozen of states in the next two years. The state fiscal crisis will overwhelm concerns about the speed of the migration, and it will result in over $200 Billion in new annualized premiums for plans in the next 3 years. The duals are now affirmed as the biggest opportunity for health insurers in a generation — bigger than the exchanges. They're also the most vulnerable, complex and expensive patients in the entire US health system and will challenge health plans like never before.
Medicare Advantage and Part D will continue on the course set by the ACA, and we expect the consolidations within the industry to accelerate with the election's uncertainty resolved. Look for a much tougher CMS in a second Obama term, with a continued increase in oversight, bolder regulations raising the bar, and a tougher compliance posture from CMS for Medicare Advantage and Part D plans.
- The Stars program's current trends will continue: Standards will change every year and underperforming plans will be hunted down and eliminated. CMS may get moving on SNP-specific rating standards, as SNP plans will be in trouble soon without them. Plans with 4+ Stars will continue to get bonuses and rebates under the ACA, but 2013 will usher in a new era of sub-3 Star plans being shut down by a much tougher CMS.
- CMS will keep trying to find a better way to risk adjust. We expect an attempt to recalibrate the HCC coefficients based on encounter data, which will change the dynamic: Plans will have to find missing codes to avoid being cut, rather than getting paid more. How CMS adjusts for the FFS error rate will be crucial.
- SNP and 1876 reauthorizations will both get paid for, but we need a vehicle to get the 1876 extension quickly, since it expires the end of December 2012. SNPs expire at the end of 2013, and so have more time for reauthorization.
Medicare: We expect Medicare will serve as a piggy bank for deficit-reduction proposals, given its size and fiscal situation.
- The Ryan/Wyden Medicare reform proposal will be debated as a gesture of "cross the aisle" goodwill from the President, but won't come close to enactment. But "premium support" will go mainstream in the debate and become more palatable over time — it reeks of inevitability and Democrats must come to the table to save the program we all hold so dear. The discussion begun by Ryan and Wyden must have its day.
- We expect the cuts that have been considered in prior budget proposals will be back on the table, including: fraud detection, reforming Medicare cost sharing rules, restricting first dollar coverage in Medigap, extending Medicaid drug rebates to duals and LIS, and more means testing. Provider cuts will also be on the table, especially for hospitals.
- An increase in the eligibility age to 67 is a possibility. But unlike with Social Security, deferring the eligibility age merely cuts off the lowest-cost tail of the distribution. The cost reduction would be disproportionately small compared to the number of people politicians would upset.
ACOs: with the ACA intact, the truly astounding surge in ACOs participating in Medicare, Medicaid and the commercial market will continue. Over 100 ACOs are already operating in Medicare. Over 500 applications were received by CMS for the September filing deadline for the Medicare Shared Savings Program, and over 300 ACOs are active in the commercial market and Medicaid reforms. With the election ACOs are here to stay as the bedrock contracting vehicle for the evolution and enrichment of forward-looking providers.
While it ended up a "status quo election" it gave the Affordable Care Act an indelible kiss of life and ushers in one of the biggest changes in our domestic policy in a generation. Now it's time to get down to the real work of implementing it.
Medicare ACO's: Tool for Reducing Medicare costs or something more?
The June 18th blog by my colleague and friend William MacBain posed a valid question when he asked whether Medicare ACO's are a revolution in healthcare or a side show. My view--it's that and more. To the point that Medicare ACO's will probably have only a minor impact on overall Medicare expenditures, I totally agree but would argue that significantly reducing Medicare expenses is not the overriding goal of the CMS sponsored shared savings program. I believe the overriding goal is to stimulate provider change in how healhcare is priced, delivered and made accessible to those who need it.
To the question of whether Medicare ACO's are a sideshow, I would respond with yes but in a good way--meaning that ACO's, Medicare sponsored or not, have helped ramp up the level of dialogue and drawn attention to the reality that change is coming to the healthcare industry, that it will come in many forms and that ACO's are one model for implementing such change. ACo's are not the magic cure for what ails the healthcare industry but ACO's do begin to address some of the symptoms -- that is a good thing.
The Supremes Say the Mandate is Constitutional. But Voters Get the Final Word.
Washington's best-kept secret since JFK and Marilyn Monroe came out today: the Supreme Court upheld the individual mandate in the ACA in a 5-4 decision made by Chief Justice John Roberts. The President ducked a bullet in the ruling and comes out strong heading into the election on this issue; the decision will galvanize the right and embolden the left; and Chief Roberts finessed the issue by calling the mandate a tax, avoiding new precedent and getting the Supremes out of the nastiest domestic squabble since Bush v. Gore. But the Supremes didn't get the last word on the ACA: that rests with the voters in November. Making Obama a one-termer is now the GOP's only hope to stop health reform.
The Supremes' decision means reform moves forward without delay. That means most of the 26 Red States that brought the case to the Court, and a handful of others, are now WAY behind in implementation and will likely have the Federal Exchange jammed down their throats in January 2014 for their intransigence. That's the Supreme irony of the case: for all their bitching about a government takeover, that's exactly what those states will get for having done nothing while the case worked its way through the Courts.
The decision also means there is no impact whatsoever to Medicare. The cuts to Medicare Advantage (MA) remain and will continue to be phased in. The Star Ratings bonuses and rebates remain untouched. The new Part D coverage expansions -- the "jelly" in the donut hole -- are as sweet as ever. Accountable Care Organizations (ACOs) move forward. Minimum medical loss ratios (MLRs) take effect in Medicare Advantage in 2014. The coding intensity adjustment in MA remains. The Retiree Drug Subsidy (RDS) continues to phase down by 2016, compelling more employers to push their retirees into MA and Prescription Drug-only Plans. Insurer and provider taxes stay put. And 9 Million Dual Eligibles continue their march into health plans. It's as if the case never happened. And that means, as we've said many times here, it's still all about Star Ratings, Risk Adjustment, and chronic care management as keys to survival in Medicare this decade.
Now the only thing standing in the way of ACA implementation in January 2014 is if Obama is deposed in November and the GOP can get enough votes for "repeal and replace". Republican nominee Mitt Romney -- the original baby-daddy of the individual mandate in Massachusetts -- said he raised over $1M in campaign contributions in the first two hours after the decision came down. Obama will use the decision to try to reboot his health reform message. And the election becomes a referendum on the ACA.
Strap on your crash helmet and hold onto your butt -- the next 4 months will be the nastiest campaign cycle this country has ever seen. But for now, the ACA lives. And if you're in health care, you should be turning cartwheels today.
Medicare ACOs: Revolution or Side Show?
CMS Deputy Administrator Jon Blum said last Thursday that the agency expects to double the number of ACOs operating in Medicare by the end of this year. That would put the total number of Medicare ACOs at about 130 by January.
Assume 130 Medicare ACOs at 15,000 bennies each on average. That's about 2 million lives, or about 4% of the 48 million Medicare beneficiaries. Presumably the ACO beneficiaries generate a little less than 4% of Medicare spending, since the 28% of Medicare members who are in Medicare Advantage still generate an average per capita payment that is greater than Medicare FFS.
If the ACOs generate average savings of 10%, and they get at least half of the savings back in performance bonuses, that's a net savings to CMS of 5% or less after savings are shared, for less than 4% of Medicare spending. That will bend the curve by less than 2/10%. That's not revolutionary.
In three years, when the savings target is reset at a level that includes some of the ACO's prior savings, CMS will capture all of those prior savings, and share only incremental savings. That would bend the curve a bit more if all the ACOs continue to play, but which ACOs are going to stay in the game when the renewal benchmark wipes out much of their hard-earned savings?
Don't waste your travel budget
We're less than three months from the GHG Forum. This is NOT your usual conference. We've developed a unique educational retreat for management teams working in government programs. I'm thrilled at the presentations our faculty are preparing: we're putting our senior consultants on the stage to deliver case studies, war stories and tales of best practices. But just as importantly, we're building in time for you to react to these sessions with your team--- to develop questions for your track faculty, compare notes, discuss implementing the best practices you've learned about.
We know it's a new concept in an industry that's become accustomed to sales people masquerading as subject matter experts. But we think that's it's badly needed. Many management teams we work with bemoan the lack of time and space to learn, collaborate and plan for success. In this environment, it's easy to simply react. But no one has ever reacted their way to excellence.
No doubt, if you send one to two people they will benefit individually. But isn't the isolation of our departments from each other central to our basic challenge of reforming our plans? We invite you to join other plans (some are sending as many as a dozen attendees) in making the GHG Forum your travel investment for the year. Send a team. We'll show you around.
When Worlds Collide: ACOs and Risk Adjustment
By John Nimsky & RaeAnn Grossman
As we enter the era of ACOs, we have to be aware of all the clinical and operational essentials that are needed to make the ACO a viable health care solution for members, plus the elements needed to support the ACO as an engaged and intelligent communicator with CMS.
If you have a shared cost saving ACO you must have an accurate picture of the member's health status at Day 1. This detailed clinical picture will help you as an ACO:
1) engage the member in appropriate care programs
2) understand their cost today and project cost for next year, and
3) calculate the risks and benefits of treatment.
In traditional Medicare, it is well substantiated that over 75% of the members may have undocumented HCCs or gaps in care. However, as an ACO your primary concern is wellness and cost saving, and so you want to push toward 100% member evaluation completion for each calendar year. Why? Your members really should be evaluated to ensure there is a documented, compliant health status profile of of each member who starts with your ACO, and each year thereafter.
If you stratify the patient population within the ACO for relative health status, your plan for future treatment intervention will include identification of those members who can benefit from:
• referrals to case management;
• inclusion in disease registries;
• and other target services on a one to one basis.
Effective population stratification and risk assessment produces a complete health profile, a tool that can help reduce:
• admits;
• re-admits;
• acute utilization;
• ER visits;
• and other avoidable costs found in today's fragmented approach to health services delivery
Specifically, a robust risk assessment approach for a defined populations will
a) identify ACO members who will benefit from treatment but are currently missed by the system and thus are more likely to develop more serious pathologies later;
b) give physicians and members/patients quantitative information about the risks of adverse events and the benefits of treatment;
c) identify priorities for appropriate outreach programs; and
d) assist in calculating appropriate benchmarks and shared savings incentives for physicians.
An in-office or in-home assessment of the patient's medical history and current health status, when appropriately employed at the time of member assignment to an ACO, is a powerful tool that must be ready to launch Day 1 of ACO implementation. Because members are likely to join the ACO throughout the year, the stratification for those new members must occur monthly and integration into the care pathway must be timely and seamless. Timely integration of the member into standardized clinical treatment approaches will lessen the burden on care givers and will ensure that services are provided efficiently and in the appropriate setting. This is not a time for a long implementation phase, lags in data refreshes, or delays in re-stratifying members.
One of the tools available to assist in the process of identifying member current health status and treatment planning is offered by CenseoHealth, which has ACO Advanced Evaluation modules for Medicare, Medicaid, and commercial members. These populations' clinical conditions differ, and so their outreach, analytics, and engagement strategies are also dissimilar.
The End of Health Insurance?
Writing in the January 30 New York Times, Zeke Emanuel and Jeffrey Lieberman predict that accountable care organizations will totally replace health insurance within the next eight years.
They credit the health care reform act with establishing this revolutionary new form of care, in which claim processing is unnecessary, and ACOs will perform the risk-pooling function of insurance. This is uninformed twaddle raised to breathtaking heights.
First of all, the affordable care act did not create accountable care organizations. They have been around, under different names such as capitated physician groups and independent practice associations, since the San Joaquin Foundation for Medical Care pioneered the concept in the 1950s. If the notion of capitated groups of physicians hasn't supplanted health insurance over the past sixty years, it's hard to understand how the affordable care act will suddenly cause that effect now.
What the ACA did do was authorize a variant of ACO as an adjunct to the fee-for-service Medicare program (and set up a largely ignored demonstration program for pediatric ACOs under Medicaid). Unlike the imaginary ACO that Emanuel and Lieberman conjure up, the Affordable Care Act version is based on fee for service payments, not capitation. While the Pioneer demo program will experiment with capitation, the vanilla ACO version authorized under health care reform requires that all healthcare providers continue to submit claims and receive fee payments from Medicare. How does this threaten health insurance? It doesn't touch the non-Medicare world at all, and it consciously avoids changing benefits or payment mechanisms in the nation's largest health insurance scheme, Medicare itself.
Emanuel and Lieberman assume that ACOs will be paid on a per capita basis, and that the capitation will somehow flow from the ACO to individual practitioners. In practice, this process requires the enrollment and claim processing functions of an insurance company. From whom, if not insurance companies, will payment be received? They rightly note that about 60% of people who receive coverage from employers are actually insured by the employer, who contracts with an insurance company to perform the tasks of determining eligibility, paying claims, maintaining networks of health care providers (including ACOs of various descriptions), and providing insurance to protect the employer from unusually large claims. How would a Medicare program designed to reward efficiency have any impact on these employer programs?
They envision ACOs pooling risk for populations of 15,000 or more beneficiaries, as insurance companies do now. Any that do so will come under state insurance statues, and will either have to become insurance companies themselves, or contract with insurance companies as risk-bearing provider organizations. Someone, either the ACO or an upstream carrier, will have to carry the reserves and comply with state mandates.
With the advent of health insurance exchanges, it is probably that local provider organizations will be able to develop and market their own insurance plans in competition with the national giants. The exchanges will create a retail marketplace in which the advantages enjoyed by the large carriers in marketing wholesale to employers will be diluted. But make no mistake, these new entrants will still be insurance companies, and will still need to operate in compliance with both the statutory requirements and economic realities that govern the business of health insurance.
Don't Throw Away Your Insurance Card Just Yet
I just can't resist commenting on the January 30th commentary in The New York Times by Ezekiel Emanuel and Jeffrey Liebman on the demise of the Insurance industry by 2020 at the hands of an explosion of Accountable Care Organizations.
To test that premise, let's go back to the role that insurance companies play in the health care market place. Insurance companies, otherwise known as payers, provide a financial safety net to consumers of health care services by aggregating different types of providers willing to provide health care services to consumers at a predetermined price. The insurance companies in turn contract with employers and individuals to provide that network for a cost to the employers or individuals ( usually the cost is shared). That cost, referred to as a premium, is determined by various factors that speak to how often the covered individual has used healthcare services in the past and based on that history how often the insurance company believes that the patient will access health services in the future, (usually the future is defined in annual increments) and by what the market place has priced the value of that service to be.
Said differently, the insurance company plays the role of a middleman between purchaser and supplier. In that role the insurance company also does something else, namely the aggregation of a lot of information about you and me regarding our utilization of health services and the consequent extrapolated assumptions about our lifestyle. Such data aquisition becomes a valuable commodity not easily or cheaply replicated by other organizations including self insured employers or ACOs.
What about ACOs? The Accountable Care Organization is typically either a provider sponsored or payer sponsored enterprise. In either case the ACO stakeholders include providers, patients or consumers and the payer/insurance company--in the absence of the insurance company the payer is the emloyer, the government, small business group purchasers, or the individual. The purpose of the ACO is to provide a framework for delivering the right service in the right setting, at the right time and for the most reasonable cost. The purpose is not to replace the payer, in fact the payer becomes a necessary strategic partner for ACOs with respect to information sharing, sharing of risk based on aggregation of defined populations via disease stratefication, etc.
The authors reference several benefits of an ACO which they assume will trigger the demise of insurance companies such as payment shifting from FFS to a fixed amount per patient; ACOs making money by keeping patients healthy; ACOs pooling patient acuity and consequent risk by capturing large groups of patients thus pooling risk; ACOs eliminating administrative costs such as those associated with claims billing and processing, and in general by eliminating unnecessary tests and procedures.
Those benefits can and should be realized by an ACO if everything goes according to plan. Those same benefits can also be realized by other types of health care redesign initiatives such as medical homes, or by payer sponsored networks of excellence or by Integrated delivery system service line initiatives or by any number of different approaches to providing improved coordinated care.
The bottom line is that ACOs will play a significant role in the movement to redefine how healthcare services are delivered, priced and paid for. They are a tool in the arsenal of healthcare reform. They also differ in character, scope and focus from enterprise to enterprise. Do they represent the successor to insurance companies as we know them today? I think not.
WSJ asks, "Can ACOs Improve Health Care While reducing Costs?"
Specifically the question that the WSJ posed in its article on January 23 to three health industry experts, (Don Berwick, former CMS Administrator, Jeff Goldsmith, President of Health Futures and Tom Scully, CMS Administrator from 2001-2004) was whether ACOs are the answer to what ails the health care system. As expected, the response from each of the three respondents differed in outlook, driven by their political, professional and personal perspective.
Don Berwick as the "architect" of a series of innovate healthcare delivery demonstration programs, including Medicare ACO's, obviously is pro ACO - citing the goals inherent in ACO formation as improved quality of services, access and consumer choice, provided at a reasonable cost and accomplished by changing the relationship between provider, consumer and payer.
Mr Goldsmith questions the value of ACO's, citing that ACO's are self serving, not provider friendly, expensive to implement, (an ACO implemented in a midsized market will cost about 30 million) and most importantly don't save patients any money while dictating to the patient the timing, type and quality of treatment available.
Mr. Scully takes a more middle of the road approach, indicating that he likes what Mr Berwick is trying to do but argues that programs like ACO are not significant change agents with respect to timing and incentives. In his opinion ACO are just one minor part of a much larger solution, as yet undefined, that must be achieved to effect significant change in how the US provides healthcare. He does go on to offer a number of recommendations as to how to pay providers, believing as so many do that financial incentives are a more effective tool for changing provider and consumer behavior than any other.
My response is that their opinions about what is good and not so good about ACO's and what is needed to get us out of the healthcare mess we are in is reflective of the debate as a whole. Namely that there is no one size fits all solution to what ails healthcare as it is provided and priced.
ACO's are not a panacea solution for what ails health care. It is not a model that can be replicated in all parts of the US via a rubber stamp process. The financial drivers underpinning the ACO enterprise is not a win/win proposition for everyone that makes a living from the healthcare industry.
Accountable Care Organizations are one tool out of an as yet ill defined tool box designed to help "fix" a healthcare system that is crashing around our ears. ACO's offer a pathway for better coordination of services, better communication between provider and patients, a hopefully more realistic approach to patient diagnosis and treatment planning and ultimately a framework within which patients are more engaged in deciding what is best for them when it comes to healthcare,.
Oh and about that 30 million dollar pricetag for implementing an ACO. Think about what an ACO is to do, i.e. organize care, offfer access to that care and provide better patient" thru put" in the inpatient and outpatient setting. Does that really cost 30 million to accomplish per enterprise?
We spend a lot of time, energy and resources talking about and reacting to the shortcomings of our approach to health services provision and pricing. Those critical of initiatives like the ACO enterprise argue that it is not new, hasn't worked , is doomed to fail, etc.. What strikes me is that we spend a lot of time looking backwards to chart the future. Doing so makes it difficult to see what might be ahead when focused on what was and is.
I believe that every problem has a solution and sometimes those solutions are not grounded in the past but are new, innovative and to coin a phrase, (just kidding) must reflect out of the box thinking. Anyone up to the challenge?