Obamacare in action--ACOs and what they mean to you

[Nilf]

Greetings.

http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=20

What are Accountable Care Organizations?

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.

Translation: Noone really knows what ACOs are, but somehow they are supposed to save money. How? The next section explains...

Shared Savings. Spending for the population of patients in a particular ACO could be compared to targets based on past experience for the same patients, or to spending for similar patients in the community who were not assigned to the ACO. If the ACO was found to have saved money, it would receive some share of the savings. Just how the savings would be divided among the participating providers is a major question that each ACO will need to resolve on its own.


# Evolution Toward Stronger Incentives. In the beginning, there would be no downside risk: The ACO would not share in the losses if treatment of its patients cost more than expected, though this could change over time.

In other words: BUNDLING and CAPITATION.

Medicare and major private insurers capitate a payment for each patient or each episode of care. If patient is very sick and needs a lot of care, the doctors will likely loose money.

Capitation model is hardly new. It mostly failed because it gave doctors incentive to give as little care as possible, and to cherrypick healthier patients.

Now, however, there is a clout of the federal government behind it. Doctors will be virtually forced to become part of these ACOs--there are numerous paragraphs about this in the healthcare bill. There won't be any cherrypicking or fussing on the part of providers.

Needless to say... this will be really really bad for your paycheck, and really really bad for your autonomy as a doctor. During my job interview trail I spoke about bundling and how it will affect pathology business when implemented... Everybody sounded scared. Most places were very upfront about the fact that they cannot guarantee any sort of bonus when this thing really goes through.

Those are THE issues to consider when you ponder your decision whether to pursue medicine.

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[Trexate]

Time for the monthly Nilf thread.

Bump for great justice.

 

[flip26]

Time for the monthly Nilf thread.

Bump for great justice.

Did you read his post, or the link?

Nilf is hated on SDN because he doesn't blow sunshine up everyone's ***** - he raises many points worth examining. Pre meds would be wise to get all sides of the story.

I welcome his input.

 

[Trexate]

Nilf is hated on SDN because he doesn't blow sunshine up everyone's ***** - he raises many points worth examining. Pre meds would be wise to get all sides of the story.

I welcome his input.

Hence the bump.

 

[Janieve]

Those are THE issues to consider when you ponder your decision whether to pursue medicine.

Thank you for arbitrarily deciding what issues I should personally and professionally consider as I pursue medicine. Clearly, everyone feels exactly the same way you do about current events and legislation, and everyone is going to focus primarily on the issues you believe are most important.

And frankly, although it hurts a little more every time I hear someone call it "Obamacare", I have read and considered the information given about the new health care system, seen the arguments on both sides, and decided where I stand on the issue. While I appreciate your efforts to encourage this sort of behavior in other members, I think you'll find them more likely to respond with hostility when you approach it like this.

Or is that your aim?

 

[anders11]

Translation: Noone really knows what ACOs are, but somehow they are supposed to save money. How? The next section explains...

1. Don't make me link you to lmgtfy. People know what they are. The Mayo Clinic and The Cleveland Clinic are both go-to examples of ACOs. They're not exactly a scary foreign threat. They're becoming more commonly known as a "group-employed model" or GEM.

2. In fact, they do save money. Over the last 10 years, ACO models have provided better than average care despite saving costs. (http://www.washingtonpost.com/wp-dyn/content/article/2009/12/18/AR2009121803890.html)

In an ACO, the physicians are paid a flat salary rather than being paid in accordance with the insurance of the patient their treating. While this can result in less pay for the physician, it also results in less paperwork and office work, and more of their time focused on what they actually went to med school to train for.

Physicians today seem to have many reasons for disliking medicine. For those whose reason is a low paycheck, no, this model won't help them. For those who hate that they were sold a deal about "helping others" when the majority of their job is about breaking even or building a business, this model is something to look into.

So no, it's probably not for every physician, but your article doesn't actually provide the slightest bit of evidence that the ACO model will become standard. That's an incredible amount of speculation.

 

[Narmerguy]

Did you read his post, or the link?

Nilf is hated on SDN because he doesn't blow sunshine up everyone's ***** - he raises many points worth examining. Pre meds would be wise to get all sides of the story.

I welcome his input.

I generally agree. Though I don't agree with most of what he says, the potential for possibly finding out I was wrong about something and correcting my faulty views makes me look forward to his posts.

 

[Kaustikos]

I generally agree. Though I don't agree with most of what he says, the potential for possibly finding out I was wrong about something and correcting my faulty views makes me look forward to his posts.

I just imagine Dr. Cox writing this. It helps...a lot

 

[RogueUnicorn]

as always, tl;dr

 

[flip26]

I generally agree. Though I don't agree with most of what he says, the potential for possibly finding out I was wrong about something and correcting my faulty views makes me look forward to his posts.

yes, his editorializing is usually over the top, but I look past that at the kernel of truth, if there is one...and there usually is.

 

[Paladin7]

Based on my understanding of this ACO concept, the creation of ACO's seems to be a well-intentioned response to certain real problems within the system (high costs, lack of communication/integration within current system, etc.). It seems like if done properly, ACO's could improve the qualitiy of patient care.

The OP mentions decreased doctor autonomy and salary. If these are indeed drawbacks of ACO's, are they the only drawbacks? And does a better solution (a solution to the problems that ACO's are intended to address) exist?

 

[Kaustikos]

Translation: Noone really knows what ACOs are, but somehow they are supposed to save money. How? The next section explains...

Shared Savings. Spending for the population of patients in a particular ACO could be compared to targets based on past experience for the same patients, or to spending for similar patients in the community who were not assigned to the ACO. If the ACO was found to have saved money, it would receive some share of the savings. Just how the savings would be divided among the participating providers is a major question that each ACO will need to resolve on its own.


# Evolution Toward Stronger Incentives. In the beginning, there would be no downside risk: The ACO would not share in the losses if treatment of its patients cost more than expected, though this could change over time.

It looks nice on paper - but they don't offer incentives for small practices to join this with their investments. They say that the ACO might give most initial profit/savings to the practices, but don't explicitely state that. To me, it means that practices might suffer for trying this.

In other words: BUNDLING and CAPITATION.

Medicare and major private insurers capitate a payment for each patient or each episode of care. If patient is very sick and needs a lot of care, the doctors will likely loose money.

I've already heard about this bull****. If I'm following this correctly, it follows the same thing that medicare/medicaid has tried to do to hospitals - questioning physician tests/care to the dot, sometimes evening asking why a bilirubin test was done on a neonate (Yes, they asked) to try and remove some of the cost responsibility. If this goes into effect, I just think this will become more of an issue to more physicians.

Capitation model is hardly new. It mostly failed because it gave doctors incentive to give as little care as possible, and to cherrypick healthier patients.

Hell, I'd do it. If insurance is going to question every call, I'll do the minimum to save money. But where does the responsibility fall? I've never learned where the responsiblity falls on a physician who does the minimum because the insurance might refuse to pay the doctor for the test he/she wanted to run.

Now, however, there is a clout of the federal government behind it. Doctors will be virtually forced to become part of these ACOs--there are numerous paragraphs about this in the healthcare bill. There won't be any cherrypicking or fussing on the part of providers.

Will this include the annoying "quality of care" survey medicare/medicaid has started to incorporate into their overall assessment of how much the hospital will be reimbursed/paid for taking care of the patient?


Good read

 

[Kevin Baker]

The health care reform legislation authorizes the Medicare program to contract (ACOs). These are networks of physicians and other providers that could work together to reduce costs for a defined patient population....



Shared Savings. Spending for the population of patients in a particular ACO could be compared to targets based on past experience for the same patients, or to spending for similar patients in the community who were not assigned to the ACO. If the ACO was found to have saved money, it would receive some share of the savings.

Hmm, it sort of sounds like a system where we add incentives for doctors who can do the same job cheaper and/or use novel approaches. And we reward (read increase) their paycheck for doing this. And we are adding this to an already non transparent system with huge barriers to entry and relatively little domestic competition.

It almost sounds like, gasp, market solutions being used to better an oligopoly or natural monopoly type of system. But let's just label it anti american socialism anyways.

 

[tweek125]

This wouldn't be a problem if we had a universal healthcare system...but n0o0o0o0o0o0o, that would be socialist...

 

[Kaustikos]

Hmm, it sort of sounds like a system where we add incentives for doctors who can do the same job cheaper and/or use novel approaches. And we reward (read increase) their paycheck for doing this. And we are adding this to an already non transparent system with huge barriers to entry and relatively little domestic competition.

It almost sounds like, gasp, market solutions being used to better an oligopoly or natural monopoly type of system. But let's just label it anti american socialism anyways.

You're right. Doctors should just tell patients to use herbal remedies and walk it off. Problem solved.🙄

 

[morning]

Did you read his post, or the link?

Nilf is hated on SDN because he doesn't blow sunshine up everyone's ***** - he raises many points worth examining. Pre meds would be wise to get all sides of the story.

I welcome his input.

You could get the same stuff with less moralizing elsewhere, if you're interested in healthcare policy. The thing is that even when Nilf isn't actively trying to dissuade people from going into medicine, it's still the agenda behind his posts, however innocent some of them may seem.

 

[flip26]

You could get the same stuff with less moralizing elsewhere, if you're interested in healthcare policy. The thing is that even when Nilf isn't actively trying to dissuade people from going into medicine, it's still the agenda behind his posts, however innocent some of them may seem.

True that you can get it elsewhere, and I am interested, but I always appreciate him or anyone else posting it, even if I disgree with their opinion.

 

[Nilf]

I am not well-versed on healthcare reform issues and currently not equipped to defend myself properly in a healthcare reform debate. So for the love of all things good, please don't attack me---I am just asking for a little help understanding here.

Based on my understanding of this ACO concept, the creation of ACO's seems to be a well-intentioned response to certain real problems within the system (high costs, lack of communication/integration within current system, etc.). It seems like if done properly, ACO's could improve the qualitiy of patient care.

The OP mentions decreased doctor autonomy and salary. If these are indeed drawbacks of ACO's, are they the only drawbacks? And does a better solution (a solution to the problems that ACO's are intended to address) exist?

The concept of ACOs is murky at the moment and differently understood by all involved parties. However, the language of the healthcare bill sounds like it will be a tool for 'bundling', AKA capitation.

Now, now... what's wrong with bundling, you may ask? In theory, it awards cost-effective, high quality care? Well so much for theory; in practice it will simply put a cap on how much you can spend, and how much care you can deliver.

How it will play out in real world is anybody's guess. I only know what the folks in my own field (pathology) are saying: private groups are expecting a big hit, they just don't know how big. I was told not to count on any bonuses. There is a spirit of uncertainty at the moment... I don't have private practice experience, but my guess is a lot of groups will be bought or closed after the bundling is implemented.

Drawbacks that you are asking about... here is pathology perspective... If there is a monetary cap on how much you can spend on a case, I will be under pressure to cut corners and skip on more expensive studies... The rules will often collide with your clinical judgement and add to your daily stress. On micromanagement level, it would be my boss telling me that I cannot order immunostains or flow cytometry on a case (for instance).

Redtape is nothing new in medicine; when I was considering medschool, HMOs were the boogeymen and i've read many a stories about how mean beaurocratic pennypinchers are making doctor's life difficult... Under the new law, with added weight of the federal government, these problems will increase exponentially.

 

[loveoforganic]

Assuming that's the case, it seems like it would really exacerbate the problem with the lack of tort reform. Yes?

 

[Kaustikos]

Assuming that's the case, it seems like it would really exacerbate the problem with the lack of tort reform. Yes?

Has the government EVER correctly predicted returns on expenditures? I would love to see the percentage of patients that become healthier and thus save hospital group money. It's come from experience working in a ****ing pharmacy that patients increase their dosage of meds and require it more frequently. How is this going to work? 🙄

 

[DrTroll]

Seems nobody really knows how it works and everybody have a strong opinion about it.

Only time could tell if it works. If it doesn't work, I'm sure ppl will come up new ways to make healthcare feasible or improve upon it. If it does, then great for everybody.

Let's give it a few years see how it goes then maybe argue about it with more facts than just what WE THOUGHT is gonna happen.

 

[Parts Unknown]

In other words: BUNDLING and CAPITATION.

Bundling is the new capitation.

I have to ask, in lieu of FFS, what payment system would you prefer?

 

[Cramster]

Did you read his post, or the link?

Nilf is hated on SDN because he doesn't blow sunshine up everyone's ***** - he raises many points worth examining. Pre meds would be wise to get all sides of the story.

I welcome his input.

I like nilf's posts to be honest.

KEEP'EM COMING MAN!!!