Friday, October 29, 2010

ACO's Revisited: Connecting the Dots, Part 1

And so the end-game is revealed:

■ Data Point 1:

"A new survey demonstrates that very few doctors believe that government reform plans for the health care system will improve patient care .... 500 general practitioners and 500 hospital doctors ... found that only 22% believed the health service will be able to keep improving efficiency while implementing the planned changes ... only a quarter of those polled believed that the new health care practices would make it easier to tackle public health issues."

Given the topic of this post, it would have been even more helpful to know the breakdown of how many "regular" doc's feel that way vs how many "hospital" doc's concur. Alas and alack, we'll have to make do.

■ Data Point 2:

"The health care overhaul law closes the door on future physician-owned hospitals, requiring new ones to be open and certified by Medicare by Dec. 31. Otherwise, they'll be barred from taking part in Medicare, the health program for the elderly, as well as other federal health programs ... The facilities' rivals — non-profit community hospitals and for-profit institutions without physician investors — have long pressed Congress to curb physician facilities."

Starting to see the pattern?

■ Data Point 3:

"The idea of accountable care organizations ... is starting to attract a lot of national attention. One reason for the interest is that CMS plans to start a shared-savings program involving ACOs in 2012 ... ACOs must include primary-care physicians and must coordinate care across all care settings. But they need not include a hospital."

That last is, at best, disingenuous.


I am fortunate to have a number of physician clients, one of whom was willing to discuss the issue with me at some length. Bill (not his or her real name) and I spoke for almost an hour on this subject, and he was quite candid about what he's seeing. It helps to know that he practices in a town with just one local hospital, and we discussed the implications of that, as well:

IB: What can you tell us about ACO's [Accountable Care Organizations]?

Bill: First, this is a major hot-button issue with physicians; hospitals have become quite predatory, because they're in the driver's seat. The model for this is Medicare's "capitation" system, which is in place around the country. Basically, Medicare cuts one check, to the hospital, which then "divvies it up" to the various providers involved. So the hospital keeps some for the OR, the anesthesiologist gets a cut, the surgeon gets one, etc. Right now, the hospital can pay an outside physician, but the ACO model changes that.

IB: What do you mean?

Bill: With ACO's, the hospital can only pay physicians who are credentialed and the model encourages economic credentialing [ed: more on that in a moment]. So if I have a patient who needs, say, an earectomy, and I do that at XYZ Memorial Hospital, I can't get paid for that or, if I fight it, it's a major hassle.

IB: Well, some would say that this isn't necessarily a bad idea; after all, we've been trying for a while to get global billing on the table.

Bill: There's that, but this is different. The idea behind global billing is that the patient gets one bill, and everything's disclosed. This is different, because the hospital gets a check, and it's got to disburse the money to the various doctors and other providers. And then there's a major catch called "economic credentialing" [EC]. What EC does is look for which doctor does a given procedure the cheapest. Now, there's a counter-balance to that, because outcomes are also part of that equation: if he's doing it cheap but has a lot of follow-up care because of complications and the like, that counts against him.

In Part 2 [now posted], we discuss some implications of this practice, and then finish connecting the dots.

[Hat Tip for Doc Survey: FoIB Bob D. Hat Tip for Trendspotter post: FoIB Kelley B]
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