ACO Rules Drop…Did You Hear the Pop? and misc.

Aside from PPACA passage one year ago, no other pronouncement from Washington regarding the future of health care has garnered more attention than the rules proposed for ACO formation.  They came on March 31With the exception of the upcoming rules defining “what constitutes essential coverage,” (this will engage the public for sure—a mess, even trumping the EOL care debate I predict), the fanfare is apropos because of their complexity and the breadth of health care participants it affects.  Headlines such as, “full employment act for health-care consultants,” were expected, and more will follow.

(For a more detailed discussion on ACO definition [I do not have 2000 words today], just Google, as reviews are plentiful and the term is omnipresent in medical circles nowadays).

An aside, rather startling that a bevy of consultants are profiting, as frankly, with the reading I have done and the conversations I have had with “knowledgeable” folks, no one has answers.  On HIT/meaningful use, and quality improvement—to name two, yes, consultants provide helpful guidance, as the instruction manuals exist, sort of.  However, these are but a few of the necessary sub-components of an ACO, and frankly, I have looked at the evidence.  If you are paying an outfit big bucks to organize your system, you might as well flip a coin.  It ain’t there.

A shameless plug: if you want to learn more, and you are attending the SHM annual meeting, please join a number of us when we go full tilt on the subject at 1:15PM. We are reviewing the ACO concept, bundling, value based purchasing, etc., and staff informs me the session has high pre-registration interest already.  Yes, shameless, but I warned you.

I hasten to add that Ron Greeno, a newly inducted Master in Hospital Medicine and a good friend, is also a panel participant.  While we disagree at times, Ron has been an invaluable resource on educating me, and many others, on the virtues of medical practice on the corporate side.  He is a gentleman and yes, one smart dude.  Congrats Ron!!

Back to the evidence front, I did want to mention an interesting study I encountered last month.  It is germane to ACO’s and along with other recent publications, raises questions about provider compensation and participation in this model of care.  I have discussed the Swiss health system before, and this March ’11 release from Health Affairs is one of the more intriguing out there—again, profiling the Swiss experience.   A caveat, it is problematical to translate views from one country to another, but it may be instructive in what the future might hold in the US.

Briefly, investigators probed physicians and patients, and solicited them for answers regarding what sacrifices they would accept in order to migrate from fee for service to coordinated care practices.  Converted to dollars (they used discrete choice experiments to build their model), here is what they found:

Swiss Franc, US Dollar Conversion (~1.25)

Bottom line, docs and patients are resistant to change, and it will take more than a notice from HHS and their insurance company to shift.  The take home lesson is this is as much an experiment in finance and care, as it is in public relations.   Do not dumb down the end users and handle this badly…although with a contentious political climate like we have at present, any honest and informed effort will undergo severe (negative) scrutiny and perhaps fail at go, for all the wrong reasons.  We have to wait and see, and I recuse myself from prognostication.

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On another front—hodge podge time—don’t miss this article from the New York Times.  It always amazes me that stories involving physicians and medical practice shoot to the top of their most emailed list.  I postulate that the NYT garners an outlier set of sophisticated readers, as well as folks who have an interest in health care and how they receive it.  Regardless, the topic is popular, which makes the content ripe for appraisal.

This piece looks at a family with several generations of physicians, the youngest a recent graduate going into emergency medicine.  The overriding theme of the narrative is newer physician graduates want a life and don’t wish to slave away like prior generations of docs.  However, the “subtext” of the article, and I see it often, is the following (an amalgamated cut and paste):

–Younger doctors are deciding that the personal price of being at their patients’ beck and call is too high, while acknowledging that teams of doctors can offer a higher quality of care. So they are embracing corporate, less entrepreneurial and less intimate roles in part for the uninterrupted family time they bring.

–The beepers and cellphones that once leashed doctors to their patients and practices on nights, weekends and holidays are being abandoned.

–And the burden of trying to be all things to all of his patients became unmanageable. In 2006, after Wayne Memorial Hospital hired hospitalists — doctors who specialize in taking care of hospitalized patients — Dr. Dewar finally gave up hospital rounds.

For his hospitalized patients, the change meant putting their trust in a doctor who knew them less intimately but was more available and more adept at hospital care. “My patients are getting better care now in the hospital,” Dr. Dewar said.

And the change saved him hours of work each week. “It meant getting off the hamster wheel,” he said.

Sounds nice, but here is the thing.  Who climbs on the hamster wheel instead?  Who practices on nights and weekends, and at what price—emotional, financial, and professional?  Yes, the grass is always greener, but it reminds me of the dot com boom in the late 1990’s.  The companies that we bid into the stratosphere, and did not make stuff, and it took several years to realize that, were not the second coming.  You still needed traditional, gritty, run of the mill business to handle the dirty work.  Translation: if medicine is 24/7, medicine is 24/7, and someone has to mind the store.  There is a price for that presence.  The story needs another paragraph.  You can fill in the rest.

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Lastly, I want to recount a personal yarn.  I am a civil war buff, and this story crystallized memories of a holiday trip I made to Gettysburg in 1991 (yup, I remember the year).  My roommate was dating a girl whose parents had a house close to the battlefield.  I had never met them, although I obviously knew his girlfriend well.  A party is a party though, and I made the drive down alone to be with my friends—after a call.

To this day (no joke), I remember both her parents being the warmest and gracious hosts I have ever come across, and they embodied the “mi casa, es su casa” ethic as good as it gets.  Their home was ours.

Anyway, I struck up a conversation with her dad, and while he was not a college-educated man, he was an autodidact of the highest order—very bright—and represented to me at least, the best of what this country had to offer.  Industrious, smart, successful, and eminently likable, and the kind of person you want to watch your back.

I told him I had never been to Gettysburg, but had read about it and loved the idea of living so close to a historic site.  He immediately got the keys to his car—and mind you, there is a Memorial Day party going on—and drove me to the battlefield (almost implausibly, the booze and gobs of seafood did not matter at this point).

He spent nearly 4 hours walking me around the site, and showing me the terrain, regaling me with stories of Pickett’s Charge, Little Round Top, etc.  It was an unforgettable, made to order tour, and an inestimable experience.

The linked article is nearly a mirror of my encounter, and it really hit home.  The Gettysburg Address means more to me this day because of that visit—and mind you, Lincoln’s oratory still puts a chill down my spine.  It is a work of beauty and three paragraphs never imparted so much.  Read it.

Sadly, I never saw her dad again, nor have I been back to the site.  My roommate broke up with his girlfriend shortly thereafter, and sorrowfully, I had heard he succumbed to leukemia a year or two later.  Memories.  They are wonderful 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.

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