RETURN OF THE HMOs aka ACOs

                                      RETURN OF THE HMOs – aka ACOs

First, I must apologize in advance for a lengthy unconventional blog (I am told that a good blogger should not bore his anticipated audience with more than a page), however I think the topic is important enough that even the most ADHD amongst us will pause and read.

If you have not kept up with the Obamacare (and I don’t mean you should have read the 2000 pages of the bill, which even Nancy Pelosi, by her own admission, has not read) or simply have your head buried in the sand hoping the storm will pass and calm will prevail, now is the time to wake up, act and get involved or lose your autonomy forever.

ACOs (Accountable Care Organizations) are part of Obama health care reform, as mandated by the Affordable Care Act.  As the Health and Human Services Secretary, Kathleen Sebelius (a former chief lobbyist for the Kansas Trial Lawyers Association) puts it…. “rules we are proposing today will help (or did she mean force) teams of doctors, hospitals and other health care providers to form ACOs where they will be able to take full responsibility for the health of their patients.”  “In return, if (emphasis added) they meet the tough standards for health care quality, they will be able to share in savings that come with improving care coordination and improving health………..this will align the way we pay for care with the kind of care we (the trial lawyers lobbyist and Senators) know is most effective.”………… “Greater efficiencies from ACOs could yield savings of up to $960 million over a three-year period”.    But not surprisingly during a Q&A session, a CMS official admitted that figure could conceivably end up about $400 million lower. (Is everyone in the White House an inflator of numbers?)

Simply put, the concept is to give physicians and others in the ACO a financial incentive to make sure patients get the proper care. “One in every five Medicare beneficiaries who leaves the hospital is back within 30 days,” Sebelius said, adding that in many cases, “it is because they failed to receive the correct follow-up care.”   “An ACO will be rewarded for providing better care and investing in the health and lives of patients. ACOs are not just a new way to pay for care but a new model for the organization and delivery of care.”   The ACO model announced is…….”somewhat different ………Under such a primary care model, with one leading PCP directing a patient’s integrated care, suppliers will be at the leading edge of reducing costs through prevention and wellness. Under the ACO model, growth in home care means a cost reduction on the other side of the coin.”   Wow !

Stanfield, a CMS administrator urged all providers “to engage their hospital systems and make sure they are at the table as these ACOs are developed.”  (Good luck!)

According to the official press release from HHS, ACOs will create “incentives for health care providers to work together to treat an individual patient across care settings — including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower health care costs while meeting performance standards on quality of care and putting patients first.”   Patient and provider participation in ACOs is purely voluntary. (It must be a cruel HMO, oh sorry ACO joke! I thought it was the law).

For those interested in additional bedtime reading more information is available at: www.HealthCare.gov/news/factsheets/accountablecare03312011a.html. (I won’t assume any responsibility for Insomnia, Nightmares, Restless leg syndrome and aggressive tendencies associated with the reading, sorry your ACO does not cover that!)

Now that healthcare reform has gone from a concept to a law, big changes are ahead for everyone associated with providing healthcare to Americans. But perhaps no other group will need to adapt more than physicians, many of whom fear without doubt that their independence will be curtailed and their influence will retreat. Coupled with that fear is the belief that patients will suffer as the “art” of medicine is replaced by standardization designed by politicians and self-centered CEOs of ACOs who salivate at the dangling carrot.

Much of that standardization push can be boiled down to a desire by employers and the government to create so-called accountable care organizations, or ACOs, in the belief that better-organized, standardized care is better care, and that hospitals, physician practices, rehab centers—you name the healthcare organization—will deliver better care if it is coordinated, and if financial penalties or rewards accrue to those organizations producing better outcomes.

But ACOs largely don’t exist yet—at least not in practice—because they haven’t yet been fully defined. The ACO model is but one of many demonstration projects that the federal government will conduct under the Patient Protection and Affordable Care Act of 2010.  But let’s say it’s a demonstration project that has a lot of support from those (the Govt., large employers and self-funded plans) who see current rates of medical inflation as unsustainable.

Because the ACO has not been fully defined, there is some flexibility in its construction. And some organizations currently control many pieces of the continuum of care that will be essential to constructing the kinds of healthcare organizations policymakers say they want. Such health system supposedly will be closely integrated and each piece/provider of the system will communicate with each other about a single patient’s care to provide better care and also save money!   ACOs will include groups of primary care doctors, hospitalists, specialists, pharmacists, home healthcare services, social services and hospitals working together to administer payments, determine quality and safety benchmarks, measure performance, and distribute shared savings. (Conveniently malpractice and the trial lawyers have been left out of the equation).

Amid all this uncertainty, one thing does seem certain: There will be a constant power struggle between the hospitals and the physicians as to who will play the key part in controlling this yet to be determined ACO model.  That will for sure determine which organizations are ultimately successful at removing waste from the healthcare payment system and make the ACOs work.

Accountability to whom?

Before organizations can begin to create ACOs, they have to realize who such entities are accountable to. At first glance, most believe the ACO should be accountable to the patient. After all, that’s the person who is trying to get well, and the reason for any action taken in the first place. Regardless of who is accountable to whom, most of the penalties for noncompliance will accrue to the provider.  Oh by the way, don’t worry about hiring more staff to keep track of your patients and making sure they are taking their pills every day and are checking their blood glucose four times a day and collecting those fecal specimens to prevent colon cancer. Let the doctor hire more staff and take a financial hit!

The Secretary of HHS says this is a new model, perhaps she wasn’t   around to feel the brunt of the HMO atrocities in the 1980’s. So how is the ACO model different from the HMO model of the 80’s? There is not going to be an iota of a difference. Like the HMO model, there will be dumping of sick patients, denial of procedures and denials investigative studies and expensive treatments in the name of “cost savings” after all it is the provider who will bear the penalties for poor results. The pay for performance is flawed in its concept. It rations care, forces doctors to make decision while looking into their wallets.  The results are known from the HMO experience of the 1980’s. HMO models ultimately failed miserably but not until it had caused enough harm. The consumers got fed up with the system and sued the HMOs for denied care.  The courts decided that the HMOs were as liable as the providers in denying care. The HMO “pay for performance” is no different than that proposed with ACO model. The only difference is that the highly paid HMO CEOs (average salaries for United, Humana, Aetna HMO’s ran into 8 figures) will be replaced by equally greedy hospital administrators, their bogus alliances with the insurance companies and a handful of our frustrated colleagues who left clinical medicine (what a waste of talent and money in training these “clinicians”) to become the physician “suits” in the hopes of hitting the jackpot.

By the way, why do you think the FED is being so generous with 40-60 thousand dollars per doctor grants to adopt a “meaningful” EMR?   Think again, it helps keeps these HMO/ACO/CMS organizations keep tab on your performance and the “meaningful” data will help the ACOs figure “pay for performance”.  Forcing physicians to use technology that only helps the ACOs and the Govt. is as unlawful as the Govt. forcing you to buy health insurance or forcing you to drive a GM car over a Toyota is unlawful. Threatening physicians with penalties for not prescribing medications electronically is unlawful and likely to be challenged.

Would Uncle Sams’s credit worthiness affect health care ?

A contentious Congress finally averted a catastrophic government default but it did not calm the financial markets, undermining the credit worthiness of Uncle Sam. It is troubling to the physicians and the hospital executives, who could see their Medicare reimbursements trimmed in the process. Those potential cuts would come at a time when providers already face other major Medicare reductions. The bill did not include a “doc fix” to the Medicare reimbursement crisis and physicians have been “double crossed” by our self-centered politicians once again. Physicians are scheduled for a 29.5% decrease on January 1, 2012, unless Congress intervenes and with the current hostilities it is unlikely that it will.

The debt legislation lays out a complex path to additional Medicare pay cuts. A summary of the bill posted on the White House Web site explains that potential Medicare cuts would be “limited to the provider side” while the providers had sought reimbursement relief. The end result is disheartening as lower Medicare pay would cause many physicians to limit the number of Medicare patients they treat — thus reducing access to care. The debt ceiling/deficit reduction plan offers a potentially false promise to the patients, it guarantees benefits but, by ignoring Medicare physician payment issues, it potentially denies the actual medical care Medicare beneficiaries will be able to access. What dials up the anxiety factor further is that the bill passed by Congress does not specify how automatic cuts would be applied to Medicare, likely it will be applied to Part A and Part B (provider services).

The potential for Medicare provider cuts was not lost on The Wall Street. Stocks for healthcare companies, including those that operate hospitals. The AHA (American Hospital Association) worries that the reimbursement would be sacrificed for the sake of physicians while the physicians worry that the hospitals (a larger lobby) will take over the division and distribution of Medicare payments to the physicians as proposed by Obama Care advocates. The hospitals are proactive in opening their “own clinics” to control the healthcare “pie”. We are seeing a greater trend in the hospitals owning sub-specialty clinics to compete for the “Medicare pie.” The hospitals, with the advent of Hospitalists do not see primary care physicians being a threat and most PCP’s are being replaced by mid-level providers such as the ANP’s and the PA’s who feed the business to the hospital by utilizing their lab and radiology services.

Organized medicine has not given up petitioning Congress for the elusive doc fix, which almost became a part of the 2010 healthcare reform law before Democrats erased it because of its high cost. However AMA has repeatedly proven to be ineffective in lobbying for the profession it represents. Instead of trying to tame runaway costs through “futile” price-control solutions such as the sustainable growth rate formula we ought to encourage our Senators to introduce reforms to promote and reward quality and efficiency. Such an indirect approach to cost control would have a better chance of succeeding and would weed out the “high rolling” providers who abuse the system by providing sub-standard care by employing mid-level providers who due to lack of confidence and training over use the system and refer patients for unnecessary sub-specialty care.

What Congress needs to do is to fix the Medicare reimbursement formula that heavily favors procedures over cognitive evaluation. In the current reimbursement situation Primary Care specialists will be soon extinct and you can expect more and more healthcare dollars being wasted by mid-levels who lack the training, diagnostic skills and experience of a good Primary Care Physician.

Harbir Makin, MD
Internal Medicine

OPT OUT of Medicare

A retired public school teacher asked me a question that most of us have not given much thought to…. Why can’t I opt out of Medicare as a patient?

I thought I would post this for a discussion.

Harbir Makin MD

MEDICARE, HMOs, ALASKA

As Congress and the White House continue to debate how to reduce federal debt and raise the government’s debt ceiling before a doomsday deadline of August 2, organized medicine wonders whether the outcome will include the “doc fix” to the Medicare reimbursement crisis for which it has pled.
At least one deal on the table — the plan from the bipartisan “Gang of Six,” composed of 3 Republican and 3 Democratic senators — gives physicians what they want, or does it? Every year the physicians are threatened with notorious SGR formula (sustained growth rate) for reimbursement under the Medicare Program. On January 1, 2012 the “chopping board” will trigger a whopping 29.5% pay cut, unless the Congress acts on it now to avert it. The big question is would it be averted? With our politicians playing “dirty politics” it is likely that this issue will likely get least attention when the country is on the verge of defaulting. The “gang of six” may have it included in the current debt ceiling negotiations but how likely is it to pass with the provisions of “doc fix”.
How does Medicare (whose chief says Medicare is just another insurance company and the seniors are just its beneficiaries) expect the doctors to continue providing services to its beneficiaries with its HMO tactics and the “chopping block”? Technology is expensive and quality (that all of us have come to expect) costs money. While we all want quality health care as our birth rights (just like food, water and shelter) who is willing to pay for such quality? Medicare cuts and HMO tactics is not the solution to provide cheap and quality care. While the rest of the Nation is disgusted with HMO’s, Alaska is gearing up for a major HMO style managed care as the Hospitals and some Insurance companies look at this moment (under cover of National Health Care Debate) as a prime opportunity to ratchet down on the Providers in this State that has been long resisted by the independent spirit of the doctors who call this State their home………. Yes, it can happen in Alaska as the older generation of free spirited physicians phase out and the newer X- Generation of physicians look for an easy life style.
I constantly hear from my senior patients the question that why the Government has to force them into a “health insurance” (Medicare) that does not work for them or majority of the seniors. Why can’t they OPT-OUT of Medicare and keep the health plan that they have contributed into all their lives and the plan that works well for them?
Why should the Government have a problem with it if Medicare is “just another insurance company” as claimed by the chief of CMS, Dr. Donald Berwick? The ex- Harvard health care safety and efficiency advocate who now heads Medicare and Medicaid in Washington, told health insurance executives in Washington during his first speech that he does not advocate rationing or major “top down” government solutions to transform the health care system but on the other hand said he’ll “play tough” with those who resist a change.
(http://www.boston.com/news/politics/politicalintelligence/2010/09/berwick_new_hea.html)