Sunday, November 14, 2010

Making Accountable Care Organizations Acceptable to the Public

The most recent issue of the New England Journal of Medicine has a valuable article about the "Patient's Role in Accountable Care Organizations," by Anna Sinaiko and Meredith Rosenthal, researchers at Harvard Medical School.

The authors report that among Medicare beneficiaries, 73% of visits took place within a primary hospital and the extended multispecialty staff associated with it, and 64% of the hospital admissions were to the primary hospital. These findings suggest a tendency for us, when we are patients, to receive our care from a "clinical community." But this pattern isn't consistent enough for ACOs to work. An ACO can't take responsibility for quality and cost if a quarter of the visits and a third of hospital admissions are outside of the group.

In my own work on the issues that emerge in health plan appeals and in independent external review of health plan decisions, I've seen how often patients bridle at being asked or required to stay within the group for care. Patrick Henry was on to something basic about American culture in his "Give me liberty or give me death" speech. Or, less elegantly, the song group "The Animals" in the chorus "it's my life and I'll do what I want."

Years ago, when my employer offered a "point of service" plan as one of the health insurance options, I chose it. The plan allowed enrollees to go outside of the ACO (called "HMO" at the time), but required a substantial degree of coinsurance to do so. I was (and am) very happy with the care I receive from the ACO medical group (I used to practice in it and have used it for my care for decades), but I liked the option of going elsewhere if I needed "mechanical" care, like joint replacement or specialized neurosurgery. These services were available within the group, but I took comfort in the idea that for interventions of this kind I could look for what the business gurus call "focused factories" that specialize in providing the services.

Here's the key sentence from the Sinaiko/Rosenthal article: "There has been little discussion about binding patients to ACOs, largely because the freedom to choose one's providers is highly valued in U.S. health policy." If the "binding" force is the need to get PCP approval for going outside of the ACO, the system will ultimately generate too much conflict to succeed. If it's obvious that a service isn't available within the ACO, the PCP will not hesitate to make the referral. But what happens when a good level of care is available, but the patient believes it is not good enough and prefers to go elsewhere? If "elsewhere" is clearly of lower quality the PCP will not feel uncomfortable saying "no" and explaining the rationale. But when "elsewhere" is high quality the rationale for saying "no" is, to a substantial degree, cost containment for the ACO.

As I've argued ad infinitum, cost containment done for the right reasons in the right way is an ethical requirement, not the abomination our political discourse portrays it as being when we excoriate the crime of "rationing." But this perspective won't fly for an ACO. We're simply not mature enough as a body politic for wide acceptance of the need to share responsibility for the health care commons.

Sinaiko and Rosenthal suggest - wisely - the principle of "allow[ing] patients to share in their ACOs cost savings." This can be done by allowing access outside of the ACO but requiring patients to make a substantial contribution for that access - through a combination of higher premium for the plan with access and higher cost sharing for the outside services. This would prod me to investigate whether my wish to go outside of the ACO was "worth it" to me. Years ago, my employer steadily raised the cost of the "point of service" plan. At a certain "price point" I concluded that although I could afford the plan, it was no longer worth the cost.

Critics will argue that this approach will create wealth-based inequality. They would be right. But if ACOs provide good care, members without the additional choices will still be well cared for. Critics of the approach Sinaiko and Rosenthal describe would do better by focusing their moral ire on the degree of income inequality in U.S. society.

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