Accounting for Taste

Senate Passes Insurance Industry Aid Bill

Image by Mike Licht, NotionsCapital.com via Flickr

Today I’m feeling like the lyrics in the country song: “Can’t explain, there’s something strange about the early Fall. It’s a comfort leaving me without a care. I remain but everything around me hears the call. And tonight, I feel a change in the air.” Only the change that I’m feeling is the sweeping health reforms brought to us by our legislators and the passage of the Affordable Care Act (ACA). Let’s be clear—there’s a lot that’s undesired in our current topsy–turvy, lack of true accountability, anything goes if you have insurance, fee-for-service health care delivery model. A model, not a system: A system would imply complete coordination of care, spending money on resources that bring the greatest value, testing current delivery models ruthlessly to make sure they deliver high-quality care and cause no patient harm.

Now, the ACA wants to radically change that model by creating large integrated health delivery organizations called accountable care organizations (ACO). Primary care practices form the foundation of the ACO by creating and maintaining patient–centered medical homes (sounds cozy doesn’t it?). We’ll be jacked in to the rest of the organization electronically; offer better, higher-quality care with ‘teams.’ Insurance payers will contract with these ACOs in much the same way they did in the days of capitation: Give the ACO the financial risk and be responsible for all the health expenditures that go on in their organization, from the emergency department, to specialist visits, and to hospital stays.

But when it comes to allocating health care resources there’s really only two forces at work: Power (money) and control. As a perspective reported in the New England Journal of Medicine, these forces will decide who controls the ACO. Will it be physicians coming together to develop the systems structures and guidelines of care that everyone will agree on? Or more likely hospitals, which already have the resources (and physicians) and are willing to change their delivery of care, even if it impacts their immediate financial bottom line. The author’s of the perspective point out that whoever makes the first move may significantly affect the direction of the ACO and the new delivery of health care.

Regardless of who wins the ‘ACO wars’ one thing is also clear—there must be a decisive improvement on our current delivery of care. Not five years down the road, but within months to weeks of implementation of an ACO. After all if we’re going to “creatively destruct” our current system then patients should expect to see marked improvement in the delivery of their care. And at less cost. This means that ACO’s can’t piecemeal improvement; they must spend the time, resources and talent to completely change the way we deliver care. They must have a plan, transparently demonstrate outcomes, and not simply try to ‘change an engine on a Boeing 747 already in flight.’ As they say in business, the ACO has to ‘go big or go home.’ After all if they’re now accountable for our care then doing anything less is just not acceptable.

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About Steve P. Sanders

A general internist writing and sharing ideas and art.

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