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! 

2 cups of milk a day ideal for childrens health new research shows

New research has answered one of the most common questions parents ask their doctors: How much milk should I be giving my children? The answer is two cups per day.

"We started to research the question because professional recommendations around milk intake were unclear and doctors and parents were seeking answers," said Dr. Jonathon Maguire, a paediatrician at St. Michaels Hospital and the lead author of the study.

Dr. Maguire and his team looked at how cows milk affected body stores of iron and vitamin D – two of the most important nutrients in milk – in more than 1,300 children aged two to five years.

The results of the study appeared online in Pediatrics today.

They found that children who drank more cows milk had higher Vitamin D stores but lower iron stores.

"We saw that two cups of cows milk per day was enough to maintain adequate vitamin D levels for most children, while also maintaining iron stores. With additional cows milk, there was a further reduction in iron stores without greater benefit from vitamin D," Dr. Maguire said.

The researchers recruited healthy children during routine doctors appointments between 2008 and 2010. Parents were asked to fill out an extensive questionnaire about their childrens milk drinking habits and other factors that could affect iron and Vitamin D stores. A blood sample was obtained from each child to determine body stores of iron and Vitamin D.

The children were participating in TARGet Kids!, a unique collaboration between childrens doctors and researchers from St. Michaels Hospital and The Hospital for Sick Children. The program follows children from birth with the aim of understanding and preventing common nutrition problems in the early years and their impact on health and disease later in life.

The study also suggested that children with darker skin pigmentation may not have enough vitamin D stores during the winter months. Dr. Maguire suggested that instead of consuming more milk to increase these levels, wintertime vitamin D supplementation may be a more appropriate way of increasing vitamin D stores while preserving iron stores.

"Vitamin D deficiency in children has been linked to bone health issues and iron deficiency has been linked to anemia and delays in cognitive development," Dr. Maguire said. "Being able to answer parents questions about healthy cows milk intake is important to avoiding these potentially serious complications of low vitamin D and iron stores."

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.