The Physician's Place in the ACO

Philip Betbeze, for HealthLeaders Media , November 15, 2010
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"The care part of it is very much focused on innovations in care delivery, inclusive of the diagnostic efforts needed to understand conditions before they become acute, as well as the patient," he says.

In that case, organization is exceedingly important. A legal and management entity must be in place to take on that shared responsibility, with insurance risk being borne by the payer and delivery risk being borne by the caregiver.

At the macro level, there's a tremendous mismatch between the goals of the ACO model and the capacity of the ambulatory services needed to keep a chronic population out of the hospital and on a healthier long-term track.

"There is an insufficient supply of primary care that needs to be hammered away not only with physicians but with advanced nursing and other extended primary care professionals," Enders says.

To help with that transition, the government has included heavy investment in federally qualified health centers through the health reform act, which is a step in the right direction, Enders says. FQHCs are community-based organizations that provide comprehensive primary care and preventive care to underserved and underinsured individuals regardless of their ability to pay.

Some hospitals and health systems, especially safety-net hospitals in urban areas, may not own them but at least have informal arrangements with them so that patients can access follow-up care or even routine checkups. Those relationships will have to change such that the collaboration happens much earlier in the process, and, if hospitals hope to be the center of the ACO, they will have to work to intervene much earlier in patients' lives to cut down on the number of chronic conditions that bring patients to the hospital for acute care. Whether that arrangement can be profitable, however, is another matter entirely.

The same could be said for physician practices.

"We recognize that continuing to align ourselves with physicians by employing them and [having] joint ventures in some clinical areas look like good opportunities, but long-term prospects are unclear," says Gene Diamond, CEO of the Northern Indiana Region at Sisters of Saint Francis Health Services in Mishawaka, IN. "Is there going to be a payoff? The ACO model might really be no better than when it took the form of a managed care bet in the '90s."

With so much uncertainty among the large institutions involved in providing healthcare when it comes to ACOs, where does that put physicians?

Doctors will lead

There are varying opinions about which entity will be the distributor of a bundled payment that could be directed to an ACO. In some cases, it will make the most sense for the hospital or health system to be that entity. In others, it might be organizations affiliated with the hospital but not necessarily the hospital itself. It could conceivably be physician practices or other healthcare providers.

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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!




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