Physician Survey Shows Docs Prefer ACOs for Their Market Clout Not Quality

Physicians climb aboard the ACOs

Talk about spin.

Deloitte has released its 2013 Survey of U.S. Physicians that examines attitudes about health orm and the current practice environment. A random sample of 20,472 physicians from the AMAs master file of physicians were invited to participate.  While only 613 (a 3% response rate) surveys were returned, the DMCB thinks the results are intuitively credible. 

What was interesting was how the Deloitte writers chose to report the data.

Most interesting was the description of physician attitudes about accountable care organizations (ACOs).

Heres Deloittes word-for-word reporting:

"Physicians report that accountable care organizations (ACOs) will be successful to some extent in achieving improved quality (introduction of performance reporting and benchmarking, 37% better identification and closer management of high-risk patients, 28% and improved population health, 21%) and reduced costs (use of lower-cost treatment settings and providers, 21%)."

Exsqueeze me, but this makes the DMCB believe that a majority of respondent physicians do not believe ACOs will be successful in performance reporting and benchmarking (63%), better high risk patient identification and management (72%) or population health (79%). A similar large majority (79%) do not believe cost savings will be be achieved.

So, asks the DMCB, if the numbers are so dreary, why are physicians apparently flocking to work in ACO settings?

Says Deloitte:

"However, physicians currently working in ACOs diverge from those not in ACOs in their views on capitation bundled payments and Medicaid reimbursements. Three in 10 physicians currently working in ACOs chose to work in an ACO environment with high-quality, evidence based care standards."

So only a minority (30%) of physicians are attracted to ACOs claims that they offer high quality and evidence-based care settings?

Thats right.  Read on.....

"Physicians identify the trade-offs between larger (e.g., large medical groups, health systems, hospitals, and health insurance plans) versus solo practices. Larger practices are perceived to be better placed to secure superior third-party payer contracts and offer the greatest financial success potential, whereas solo practices are perceived to offer greater clinical autonomy. Larger work settings offer better conditions for contracting with third-party payers (89 percent of all physicians feel this way) whereas clinical autonomy was a valued feature of and more likely to be a feature of solo practices (81 percent of all physicians)."

In other words, when it comes to the grand convergence of physicians and ACOs, its not about quality and efficiency.  Its all about giving up clinical autonomy in exchange for income preservation and the market dominance that leads to local negotiating clout.  

The finding - albeit in an imperfect survey - that few docs who work in these settings have faith in the promise of increased quality or efficiency does not bode well for ACOs.

Stay tuned! 

The Rise of the Medical Director What One ACOs Good News Tells Us

Medical Directors prepare for battle

The VP of Finance finally agreed to a meeting. In order to make maximum use of their time, however, he had a simple request: submit an agenda of topics first and then hed be happy to let his administrative assistant set up an appointment.

In that game of organizational politics, Finance VP: one. Senior VP and Medical Director: zero.

The lost voice mails. The patronizing glances. The unanswered emails. The skeptical grins. The condescending nods. Every lead doctor, medical director and physician VP is exquisitely familiar with the tut-tuting attitude that lingers just below the surface, ready to spring when their opinion on how to best serve patients bumps into the organizations budgeteers. Those finance guys know that the typical physician is used to spending dollars like a Miami-Dade ICU on a 98 year-old. They know those "white coats" are incapable of understanding costs, margins and cash flow. Better that they get out of the way and let the money experts call the shots, eh?

Call it the clinical-finance tension. Like government revenue vs. cutting taxes. Sales vs. customer service. The DMCBs premium cable TV perences vs. the spouses unreasonable penny-pinching.

Which is one of the reasons why the Disease Management Care Blog found this New York Times article interesting.  If this is any indication of what is going on nationwide in the delivery of medical services, the implication is that the physician leaders perspectives are in the ascendancy in their organizations. Not only is there a pervading belief that keeping patients like Ms. Cline away from the emergency room is important for the bottom line, but that achieving clinical outcomes is no longer secondary to making budget.  While typical news reporters havent picked up on the clinical-finance tension that lurks in health insurance and delivery organizations, the very fact that most of the NYTs interviewing involves physicians is telling.

The playing field is currently level.

Which brings up four points:

1. The DMCB suspects the genesis of the NYT article was this presentation at a recent AHIP meeting.  Thanks to reading the DMCB, you also know that a lot more background detail on the Advocate-BCBS Illinois collaboration is here.

2.  Abstracts, presentations and news articles are one thing, but having results reported in a peer-reviewed setting is another.  The DMCB readers know that theyll withhold final judgment until it sees some transparently presented hard numbers.

3.  While Medical Directors are currently playing on a level playing field, disappointing budget results, financial losses and failure to achieve savings could not only tilt things against the clinicians again, itll quickly undo the merits of "doing the right thing."  That alone is a good reason to hope that the health system "accountability" arrangements like ACOs survive.

4.  The secret sauce to Advocates success?  Care Coordinators.  More on that in tomorrows post.

Care Coordinators The Commonwealth Fund Shows Why ACOs Should Fund Them

In yesterdays post on the re-emergence of the "medical director" as a force to be reckoned with, the Disease Management Care Blog also mentioned care coordinators.   Theres a reason why they were prominent feature in The New York Times recent ACO article on Advocates success.

The DMCB defines care coordinators as credentialed non-physician medical professionals - usually but not always nurses - who have three responsibilities:

1) maximizing the "health insurance benefit"  - whats often lost is the reality that insurance coverage varies and is imperfect.  It takes time and effort to match a patients clinical needs with payments, networks and limits.  That includes fee-for-service Medicare.

2) enabling the patient to address "care gaps"  - and most DMCB readers understand that that is accomplished by enabling patient participation in and control of their care.

3) maximizing community resources  - there are a host of public and private services "out there," and its a full time job to help patients access them.

While well-meaning traditionalists will argue that letting nurses into the doctor-patient relationship is a risky proposition, check out this short article that just appeared in the Archives of Internal Medicine.  Michel Doty and colleagues tapped the Commonwealth Funds 2010 International Health Policy Survey of over 19,000 adults from 11 countries.  In it, they asked respondents about the involvement of a "care coordinator" and correlated it with self-reports on the use of health care services. 

While the odds ratios vary, having a care coordinator emerged as a strongly independent and statistically significant predictor of better appointment scheduling, access to test results, specialty care and follow-up after discharge.  Patients with access to that kind of care had odds ratios in the 0.50 range, meaning that they were about half as likely to report problems.

While the Archives article is based on self-reports, is retrospective, doesnt precisely define "care coordination" and there may have issues with how that gets translated across cultures and languages, the information is telling: having a trusted third party in the mix of care services can have a powerful impact on health care utilization that leads to decreased cost and higher quality.

Last but not least, while the authors point out that "care coordination" is a bedrock principle of the Patient Centered Medical Home (PCMH), they neglected to point out that this is also basis for population health management. 

Take it from the DMCB: medical directors have little reason to care if the care coordinator is on the PCMH payroll or offered by a third party population health management vendor, just so long he or she gets the job done, maximizes the benefit, engages the patient in self care and makes sure community resources are accessed. 

Of Antifragile and Accountable Care Organizations ACOs

Emboldened by yesterdays economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns its attention to a magnificent new word:

"Antifragile."

Thats the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandoras ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCBs antifragile infatuations, recall AHERFs spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but itll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health systems antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......