• Coming back from end of week cynicism

    I gave two talks at the end of last week. The first was on Accountable Care Organizations for a local chapter of the AAP. The second was on health care reform and the health care system in general. By the end of the second talk on Friday, I was pretty much feeling despondent.

    As I reviewed ACOs on Thursday, I was talking about how many hoped they would bring about cost control at the physician level. But as I reviewed the progress of how the rules have been modified over time, I could feel cynicism creeping into my voice. There was the removal of sticks in October. The elimination of rules requiring EHRs. The reduction in quality oversight. The ability of patients to seek care outside the ACO. And let’s not forget the counterproductive side effect of provider concentration that the formation of ACOs encourages (Austin helpfully posted a FAQ on this balance of power earlier today).

    So I’m skeptical that ACOs will be what gets us out of the ditch in the future. Not that I see many other helpful ideas from others. Tort reform won’t do what people say it will. Medicaid block grants are just passing the buck. Medicare “sorta” premium support is just cost-shifting. None of these things will get us there.

    So what will, I was asked? I wish I had a magic wand to just fix things. But, more and more, I’m becoming convinced that we need to identify areas where we can save money at the local level. Wennberg’s work shows us that there are huge variations in care that don’t seem linked to quality. That stuff has to go. Berwick and Hackbarth went further and identified how much “waste” there is in the US health care system right now:

    I’m drawn to the third line alone. We’re spending somewhere betweeen $156 billion and $226 billion just on overtreatment. If we could just figure out a way to stop doing that, we’d be well on our way to bending the curve. Not that we can’t fix the other things as well. But stopping overtreatment seems like it would be the easiest to do, and it would have the added benefit of not requiring that much new added infrastructure.

    We may need to focus on where these things are occurring locally, though, instead of thinking there’s some large lever to pull at a national level. We also need to identify ways to change physician behavior, which isn’t easy. I’ve been talking much more about that in my own corner of the world. I hope others are, too.


    • Aaron
      I echo your sentiment, and feel similarly.

      More vexing however, is to get a handle on overuse and waste, we must comprehend care variations. As that suject gets more attention and analysis, and the citations grow in number, so do the contradictions. The current HA is illustrative…

      Understanding resource use at state vs HRR, HRR vs hospital, and hospital vs provider level gets more complicated. Risk adjustment, HCCs, and assessing burden of illness (in a valid fashion) makes the analysis even more difficult. Jim Reschovsky has been doing some interesting work, and has provided a nice counterpoint to the Dartmouth data. MedPAC as well has also added needed granularity.

      In the end though, even though its great for fodder for discussion, it gets to your concluding points, mainly, what the hell to do with it all, and how do you intervene without hurting patients and demoralizng providers.


    • Obviously a critical topic, and one that accounts for the largest share of cost differences between the US and European countries.

      As Brad F notes, physician culture is a huge issue here. Looking at Wennberg’s maps, the impact of splashdown by major programs in various regions is huge, causing changes in behavior both of providers directly trained or associated with the programs and by people who work beside those providers over the years. The results attained by isolated programs in areas of much higher costs — for example by Mayo in Scottsdale — show that the results can be exported, but also show that these isolated institutions have a much less significant impact on medical culture in their areas.

    • It’s too early to get despondent! ACOs are just the first step, not the endpoint for payment reform. EHRs are being adopted. The Pioneer ACO demos are more ambitious. Some of the state efforts to reform Medicaid and integrate care for dual eligibles are even more ambitious. I think we are on our way, it’s just that the move to global, quality based payments and accountability for care coordination won’t happen quickly.

    • ACOs sound like HMOs and therefore, you have to look at where HMOs failed. My guess is two issues:

      1) Established doctors’ practices had little incentive to join an HMO. Therefore, HMOs were staffed by young doctors and didn’t attract people who were more comfortable with their established doctors.

      2) Churn. Most of the benefit of an HMO was supposed to come from preventative treatment. This is a good theory, the CDC said 75% of medical cost comes from chronic disease and most chronic disease can be managed better. But this usually requires an intensive process, at the beginning. Six months to a year of work with, say, a diabetic, getting them to eat better and exercise more can have life-long effects, but the insurance company has to invest at the beginning and is unlikely to see the benefit.

      The average American stays at one job 5 years and the average company switches insurance about every 5 years, meaning, on average, an insurance company probably has an individual for 2-3 years.

    • I think stopping over treatment would actually be the most difficult of the list to accomplish. Sure care coordination and changes in delivery and care transitions seem insurmountable at times because they involve team work and changing cultures of not only docs and nurses but also of patients, but it requires changes in policies and standard work and training, which, is probably more straightforward than perfecting diagnoses. Over treatment can possibly be partially rectified if we improve our physician training and educate patients about how to better manage their health (including preventive care) but there will remain issues where conditions are too complex to know exactly which test and treatment are the right match. This will also occur in less complex conditions where other factors are in play and is possibly more routine than we realize. 

      How many times do we all go to the doctor and they give us two or more options for treatment because they are unsure of our severity or which treatment is a best match for our individual instance? There are at tomes many pathways to the end result, cure/ health. For example, it may take two or more tries to figure out the best allergy medication that produces the least side effects and best satisfaction fir the patient. Also, there are times when our providers prefer to consult with a more experienced provider to ensure the best decision is being made. This might require another visit -with its corresponding cost. True the shift from FFS will help eliminate some of this cost but to what extent can we rely in that?

      Reducing over treatment is very important especially for the patient experience but I think it is the more complex of the bunch. Our system is still quite far from achieving elimination of this and may partially rely on first tackling the other items on that list.

    • My thoughts:

      Overtreatment is probably tied to:

      1. Malpractice concerns.
      2. Patient satisfaction concerns, which is linked to #1.
      3. Specialists who get paid to do procedures, and not as much for cognitive services, which is driven by the AMA.