ACO = Answers Clearly Overdue

Public Policy Contributor Brad Flansbaum writes…

The health bill is now law.  What next for hospitalists?

Most of the chatter these days concerns access, and to a lesser extent, system reform and cost control.  In HM circles however, bundling and episode-based payments have been de rigor for 2-3 years.  Conceptually, it is rather simple to grasp what this form of payment and practice involves.  For that reason, individuals on the financial front lines have invoked these models as the next saving graces of healthcare.  I must admit, from the perspective of the overhaul stakeholders (government, employers, and insurers), I can’t blame them.  Additionally, policy wonks have sold accountable care organizations (ACO’s or “population based bundling”) as a fait accompli and a surefire solution to all that is wrong with medicine.

Here is the thing though.  As much as I buy in to the concept, really, what troubles me is my inability to find answers to important questions.  Yes, these models are new and there are no instruction manuals, but certain things–the foundations on which these models of care will sit—seem woefully deficient.

For example, I have yet to encounter one paper in the mainstream medical or health policy press that indicates where risk adjustment stands in 2010, and how ready current models are for role out in pilots.  CMS uses its HCC (Hierarchical Condition Categories) for tweaking Medicare Advantage plan payments, but some in the know tell me it’s far from perfect.  Additionally, the Netherlands, probably the nation with the most advanced risk adjustment applications, uses its unique system and with their own HIT based data collection.  What functions elsewhere, and the Dutch will tell you it is also a work in progress, does not imply immediate success here.  As they say, garbage in, garbage out and our administrative coding system has limitations—as most of us know.  When will these models be ready for wholesale prime time is anyone’s guess?  I would assume not in the near term.

Another vexing issue is quality assessment.    The premise of ACO’s is pay for population based health, and measure “quality” to insure patient safety and facilitate competition.  Well, seeing as we cannot get sacral ulcers and urinary catheters straightened out, I am interested in knowing what metrics will be applied when tens (or hundreds) of millions of dollars are exchanged and payers examine outcomes.  Mortality rates have merit at that level of measurement, but that is not adequate.

A contentious matter (or need I tell you), unless salaried in a fully integrated system, I cannot envision health providers parsing pooled dollars peacefully.  I have yet to read or have one expert tell me, not a one, how buckets of money will be divvied in a “virtual” or loosely connected network.  I have watched blood spilled at ACP and AMA meetings on this subject, and CMS and hospitals want no part in this exercise.  Arbitration might work, but by whom…and make it binding and “fair?”  Not likely. While on the matter of physicians, it also seems unlikely that wide IT adoption, even with incentives, is likely in the next 3-5 years–at least not adequate enough to generate registry level data.  While limited size practices are fading or being absorbed, a significant portion of America’s docs are still in small pods and database mastery and linkage will take a good deal more time.

Lastly, there is a major disconnect between the politicos and the practitioners regarding implementation stages.  Again, I am a big believer in this model of practice, but for the reasons above and many more I did not cite (certainly, the definition of an episode of care is worthy of its own post), we are years away from well-designed programs.  The messaging from the Hill and state capitals is dissonant and the staffers require education on current deficiencies and timelines.  Even accelerated ones, as the newly created CMS Center for Payment Innovation calls for, can’t generate lightning in a bottle—not that fast.

On the EBM scale, ACO’s (here and here) are somewhere between resveratrol and probiotics, and again, it will take several years and discussion before SHM fixes the inpatient side of medical care delivery in the context of global health service—despite our desire and willingness to make it happen.  Don’t tell CMS or Kathleen Sebelius though.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

1 Comment

  1. Jack Percelay on May 20, 2010 at 11:28 pm

    Well written and thoughtful post Brad. I think we all have to take this with a dose of uncertainty, knowing that change is inevitable, will never be perfect, but does offer improvement. I like Gawande’s analogy to local experimentation in agricultural techniques as the best approach to figure out how to improve healthcare. No one has a priori answers, and if we think we do, we are fooling ourselves.

    On a selfish, individual level, as a relatively underpaid cognitivist, I’m guessing I have more to gain and less to lose in what’s to come.

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