Accountable Care Will Depend Upon Accountable Patients            April
28, 2013

By  Leonard
Zwelling

            The
New York Times headline sums up a philosophy of health care that seems
counterintuitive., especially given the push here at Anderson to increase
patient encounters. “A Health Provider Finds Success In Keeping Hospital Beds
Empty”. The article by Annie Lowrey focuses on Advocate Health Care an
Accountable Care Organization (ACO) in Chicago. ACOs hypermanage patients using
electronic medical records (EMR), frequent provider-patient follow-up, close
supervision following hospital discharge to ward off readmission and extra
personnel to coordinate this care. The provider is paid an estimated amount to
provide care for a certain number of patients each year. If the provider can
give the care for those patients at lower cost than the payment, the provider
shares the extra money with the insurer.

            Here’s
the link to the article:

http://www.nytimes.com/2013/04/24/business/accountable-care-helping-hospitals-keep-medical-costs-dow

            I
am all for ACOs as long as there is an understanding that they are just a modification
of the old capitation system that had its heyday in the mid-90’s with the
threat of Hillary Care and the influx of managed care. What that was about then
is what it is about today. Money and risk.

            ACOs
are capitation with lipstick and EMRs. The goal is to shift from a
fee-for-service model that rewards providers for doing more to this model that
rewards providers for doing less, hopefully while maintaining quality.  In the fee-for-service sector, a full
hospital is profitable.  In an ACO,
an empty hospital is profitable.

            This
may seem an extreme overstatement of what an ACO is or is not, but in essence
the model seeks to shift some of the financial risk to the provider. What about
the patients?

            In
the end, altering human behavior has probably had a greater effect on lowering
cancer incidence and death rates than any discovery from a research laboratory
has. Right now, we can virtually end colon cancer death and have a huge impact
on the incidence and death from lung cancer as well. But having everyone get
appropriately screened for colon cancer and having all smoking cease are two
unlikely events. Nonetheless, we absolutely KNOW these things work and work to
a greater degree than any current “targeted” drug therapy. To implement these
prevention strategies, however, must be via a partnership with patients and
providers and the patients have the larger role.

            One
of the reasons health insurance premiums are likely to rise is that ObamaCare
minimizes the degree to which insurers can rate patient premiums based on their
risky behaviors (raise or lower individual premiums based on a patient’s
medical history and behaviors). It is reasonable to assume that this is likely
to drive costs up. But if we had both ACOs and APOs. Accountable Patient Organizations,
where good behavior is rewarded in a fashion well-described by Safeway CEO
Steve Burd during his talk at MD Anderson a few years ago, we might truly have
better health and lower costs. Mr. Burd has done this within his company.

            Here’s
a quote from Woody Allen’s 1983 film Zelig that sums it up pretty well:

            “You
are a great inspiration to the young of this nation who will one day grow up to
be great doctors and great patients”.

            Think
about it. Many of you are great doctors. Wouldn’t you be even greater care
givers if your patients did, not only what you asked them to do, but what their
mothers told them to do?

Leonard Zwelling