Saturday, January 31, 2015

Accountable Care Organizations, Hospitals, Primary Care, and Ptolemy vs. Copernicus

In a very interesting post, Paul Levy wonders if Accountable Care Organizations will really be the panacea for cost containment and more rational and organized medical care that some people are hoping for:

His skepticism is well founded, I think. The basic idea of ACOs came from the Dartmouth researchers, who started in the 1970's studying rural New England medical neighborhoods located around a single hospital, and found that there were small area variations in the customs of treatment. Some areas had lots more tonsillectomies than other areas, for instance, with no difference in the population. They posited that having lots of ENT doctors in an area led to more tonsillectomies, and found other such correlations as well. This was great research!

From there the concept has expanded, and every area of the country is now viewed as having the same organization as rural New England, centered around a hospital. The idea of ACOs is to take this putative neighborhood – and if there is no such neighborhood, to try to make it into one – and organize it differently, so that if a more formally organized group of doctors and hospitals can rationalize the care and make it less expensive, they can save the country money and make a little bit more themselves, by being well-coordinated and abstemious in their care.

This insight is that of corporations. If one brings all participants in a system under one roof, the processes can be rationalized, and the increased profits shared among the participants. The opposite theory is that of a market, where all elements are independent and competitive horizontally with one another, leading to more efficiencies not by corporate regulation, but by decentralized invention. Sometimes one theory works, sometimes the other theory works. The main variable in deciding which one is better is transaction costs: if they are high, it's better to go with a corporation; if they are low, a market is better.

Personally, I like a competitive market. I think a corporation should always be the second choice, because I think people will do what is comfortable for them personally unless they are forced to compete. But I have to admit that sometimes corporations can be great. Which should it be for the medical neighborhood?

The ACO concept is corporate, and indeed, the FTC needs to give ACO's a pass on anti-competitive practices for them to be established. My concern is that the way hospitals and specialists (who will most often be in charge of the ACO's) view the world is Ptolemaic. They see hospitals and tertiary centers and the specialists – the high priced elements of the system – as the center. Is this as it should be? Should these elements who drive the high cost of care, the high price of care, be at the center of power? 
Let us recall again the parable of the blind men and the elephant, each describing the whole as being the part that they are feeling. To hospitals and specialists, what they do is the core of medicine. The way they do it is the core of medicine. Put hospitals in charge and we will find ever more administrators populating the system, producing more of the same cost escalation, just as higher education costs are fueled by more and more university administrators. Put specialists in charge, and they will be driving primary care by their own lights, dishing out more and more of the current tasks of specialty clinics for the primaries to handle. The cost of care might well be reduced, and certainly the cost of specialty clinics will be reduced, and they will thus be paid more. But, they haven't thought things through. If the specialists dump more of their work on the primary care practices, what primary care tasks will these specialty tasks displace?

Little understood and valued by the hospital hubs, primary care has its own agenda. Primary care is the place where patients and doctors interact most constantly and most intimately, over a long term and many different issues great and small. Primary care is where prevention and health promotion take place. But here is where the blind men and elephant come in. Do the hospital and specialty hubs realize and value this? Not really. They call it “hand holding.” Well, yes, we do hold hands at times. That's valuable; that's important; that's human. That's what doctors are supposed to do.

But the medical care system does not value primary care services highly, literally. There is a system called RBRVS, that puts a value on everything medical. Unfortunately, specialists run the RBRVS system, and mirabile dictu, it turns out that specialist procedures are valued more highly than primary care. So specialists earn more. And since money measures all, it turns out that specialists are more valuable than primaries. It must be, then, since they are worth more, that specialists are smarter, and therefore they are worth more. And that primary care isn't worth very much, so why not have them do more specialty care?

But that's not all there is to it. People are concerned that primary care will not do their job properly under ACO's – not because they will be doing specialty work, but because the payment will be changed from fee for service to capitation. So, how do they defend against primary care dereliction of duty? Measure primary care performance! 
Well, one might think that this would indeed ensure that good primary care work was being done. And it would – if the “quality measures” worked. But they don't. They suck. People have tried, and there are many, many measures – too many, actually, and different ones employed by different measuring agencies so that there is now a movement to consolidate and have all agencies measure the same thing. But that really doesn't matter, because they only measure what is measurable, and most of the most important elements of primary care are not measurable. It is a common problem: "Not everything that counts can be counted, and not everything that can be counted counts."  (William Bruce Cameron.) 
Here's a good example: one of the most important functions of primary care is making a good diagnosis. This is completely unmeasured, yet what could be more important? I had a young mother in my office on Tuesday whose own mother just died last year at the age of 43. The story was that she seemed to have thyroid deficiency that was untreatable, no matter how many pills she took. A new doctor took over and just followed the old doctor's regimen and the patient still was no better. Then the diagnosis finally declared itself: disseminated ovarian cancer. The young mother in my office is completely devastated by the loss of her mother, and the incompetence of the care. She said she was going on a doctor strike, not seeing anyone herself, and seeing one for her son only reluctantly. She was relieved to meet me as someone who practiced in a practice with a strong reputation,and as someone whom she could obviously trust, because I was a mensch, I listened and understood and was empathetic and talked to her in the right way -- I've been at this a long time and I have learned. 
How would quality of care assessment work in the case of her mother? Not at all – they don't do diagnosis. How would it work in assessing my work in reassuring my patient (mothers are actually our patients, as you know)? Not at all, or maybe very indirectly with some general patient opinion surveys, which are in the main completely unreliable and structured for coding of answers so that promptness is equal to “listened to me,” and empathy doesn't appear. So, are we really going to count on “quality measurement” to ensure that primary care thrives in ACO's?

I'm not saying that ACOs can't work, but if they are to work, there has to be a Copernican revolution. Primary care needs to have its own center of power within the new organization. In addition, primary care needs to find its roots and find its leadership based on those roots. Its roots are in the personal relationship of trust and intimacy between doctor and patient, and in healthful guidance and advocacy from the doctor to the patient. This is just not easily measurable at present. One can't measure the end results of this process well, it's too hard to do so. If there is to be measurement, and I guess there should be, then it needs to be a process measurement. What values permeate the practices? What procedures are undertaken to ensure that positive reinforcement of these values takes place? What leadership is in place? There are lots of objective measures that can hit on this, but no one is using them now, but they should. And, we need the primary care leaders within the organizations to give the stories, give the anecdotes, promote the values, and get the rest of the system to appreciate what primary care does. 
And then finally, we need the primary care leaders to get more money for their doctors, more money for their practices, and then attract the medical students and residents to primary care, so there can be someone there to do the jobs they are promoting as so important. That's what has to happen if ACO's are going to do some significant good. The odds on this happening. Low, sorry to say. But stranger things have happened. Copernicus did emerge, and there was a revolution in his wake.

Budd Shenkin

1 comment:

  1. Thanks for posting your thoughts on the excellent Levy piece. Budd. My nature, when reading something like this, is to look for points of disagreement but I don't have any here - I think you have it just right. If anything, I'd add these supporting comments:

    - All medicine is local. You effectively make that point, but I don't think we can overemphasize it. What works in Oakland may not work in Tyler or even Berkeley. I know that I'm hardly making a revolutionary statement here and that every ACO has a different flavor, but I don't get the impression that any of the ACO construction is actually driven by local patient demand. Which leads to...

    - One of my friends represents a large hospital and he summed it up like this, "The hospital has no idea what it's doing, but it knows if it doesn't set up the ACO, someone else will and they'll be on the wrong side of the equation. This has nothing to do with saving money, it has everything to do with guarding territory. They figure they'll lose money on it, but it'll all get taken down in 3-5 years and they'll be OK." I am shocked, I tell you, shocked. ACO construction is driven by hospital and specialist demand, not by patient needs. Recipe for failure, imo.

    - The divide between the nature of primary care and specialty care is, indeed, worth highlighting. In the former, the presumption is that the patients don't get enough of it. In the latter, the presumption is that patients get too much. These two sides of medicine should be treated very differently, imo. How fascinating would it have been if the ACO language denied the ability of hospitalists or specialists to run them?

    The bottom line is that those in power already were, no surprise, to first to grab onto the ACO ring and start directing traffic. I have yet to see an ACO model that has any sense or viability as it relates to pediatrics, as a result. I'd welcome a correction. [Yes, I am aware of a some primary care driven ACOs - there's one right here in my county, I play tennis with the medical director. THIS is what an ACO should look like, imo, to be successful but it's not a popular model.]