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The Physician's Place in the ACO

Philip Betbeze, for HealthLeaders Media, November 15, 2010
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Now that healthcare reform has gone from a concept to a law, big changes are ahead for everyone associated with providing healthcare to Americans. But perhaps no other group will need to adapt more than physicians, many of whom fear that their independence will be curtailed and their influence will retreat. Coupled with that fear is the belief that patients will suffer as the "art" of medicine is replaced by standardization.

Much of that standardization push can be boiled down to a desire by employers and the government to create so-called accountable care organizations, or ACOs, in the belief that better-organized, standardized care is better care, and that hospitals, physician practices, rehab centers—you name the healthcare organization—will deliver better care if it is coordinated, and if financial penalties or rewards accrue to those organizations producing better outcomes.

But ACOs largely don't exist yet—at least not in practice—because they haven't yet been fully defined. The ACO model is but one of many demonstration projects that the federal government will conduct under the Patient Protection and Affordable Care Act of 2010, otherwise known as the health reform act. But let's say it's a demonstration project that has a lot of support from those who see current rates of medical inflation as unsustainable.

Because the ACO has not been fully defined, there is some flexibility in its construction. And some organizations currently control many pieces of the continuum of care that will be essential to constructing the kinds of healthcare organizations policymakers say they want. Such health systems, which have been known colloquially as integrated and whose pieces communicate with each other about a single patient's care, have been held up as examples of what government is seeking with ACOs. But such organizations are rare, chiefly because perverse economic incentives have made their combination economically nonsensical in a fee-for-service payment environment.

ACOs will include confederations of doctors, specialists, and hospitals working together to administer payments, determine quality and safety benchmarks, measure performance, and distribute shared savings, according to a June 2010 report from the American Hospital Association. Still, as we enter a four-year transition into new payment methodologies on which long-term strategic decisions must be made, organizations are left with making little more than educated guesses about how they might become an ACO.

Amid all this uncertainty, one thing does seem certain: The physician will play a key part—perhaps the key part—in whether such organizations are ultimately successful at removing waste from the healthcare payment system.

Accountability to whom?

Before organizations can begin to create ACOs, they have to realize who such entities are accountable to, says Tom Enders, managing director of CSC's Health Sector Group in New York. At first glance, most believe the ACO should be accountable to the patient. After all, that's the person who is trying to get well, and the reason for any action taken in the first place.

"The accountability is not unilateral; it's trilateral, for the management of care across locations and time," he says, explaining that accountability is the responsibility of the provider for sure, but also of the payer and the patient. That said, most of the penalties for noncompliance will accrue to the provider.

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2 comments on "The Physician's Place in the ACO"


John Barbuto, MD (3/11/2011 at 1:00 PM)
You make a statement which is critically flawed. You say patients "are trying to get well". That is certainly true to a large extent. But, it has subtle, critical flaws. First, patients who seek health care are certainly trying to get health care, but they are routinely trying to get the health care they "think" will make them well. They are trying to meet their belief systems - which may or may not be consonant either with optimal care or with achieving health. For example, there is a huge industry of "health care" which is purchased via health food stores or other "complementary and alternative" sources. The vast majority of these services are provided with no rigorous science behind them at all - only claims and anecdote (and maybe some inferential low order studies). In these realms the hypothesis of "evidence-based medicine" is a joke; yet, the services are consumed to the tune of many billions of dollars a year. And, this example only represents a concept which has much greater ramification even than this industry. In addition, a small but critical portion of patients come to the doctor to obtain services which support some secondary agenda - an agenda which may not be served by becoming well. So, for example, auto or industrial accident blame games, unwarranted disability pursuits, escape from responsibility, social control over others, and other "hidden agendas" lead to service which is rendered not to become well but rather to serve the hidden social agenda. This also is big business in some arenas. So, while it is true that most patients seek to become well, the most accurate statement is that patients seek health care to receive health care services - whatever agenda may be underlying the pursuit. We like the hypothesis that medicine proceeds best based on evidence-based science. But, the actual evidence is that this hypothesis is flawed in some important ways.

Gregg Masters (11/16/2010 at 2:08 PM)
Nice piece! We really need to keep the focus on the provider education perspective; via a lens of institutional memory, lest we recreate the same mistakes of the past. The scope and range of concerns, including the many competing voices for visibility in this space require attention on key narrative curation, and vetting of the many threads in this unfolding story!