• Reading list

    From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy, by Theodore Marmor and Jonathan Oberlander (Journal of General Internal Medicine)

    The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads—despite their poor record—and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the “holy grail”—a reform that will decisively curtail spending while simultaneously improving quality of care—and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, systemwide fee schedules, and concentrated purchasing.

    The Potential for Cost Savings through Bundled Episode Payments, by David M. Cutler and Kaushik Ghosh (The New England Journal of Medicine)

    Financing Graduate Medical Education — Mounting Pressure for Reform, by John K. Iglehart (The New England Journal of Medicine)

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    • If you look at Berwick and Hackbarth on the waste in health care, the evidence they reviewed estimates that failures of health care delivery and coordination compose about 18 percent of all waste – this category includes poor execution of care, not applying known best practices like patient care guidelines and clinical guidelines, failure to coordinate care that causes bad things like an unnecessary hospital readmission, injuries, etc.

      This is the ‘wedge’ of failure that ACOs try to address – and it’s only 18 percent of health care.

      The other failure categories include fraud/abuse, overtreatment, and pricing failures (meaning Dr. Carroll’s colleagues, drug and device manufacturers, hospitals, everyone else, are charging too damn much).

      Of course, failures of care coordination especially affect Medicare and Medicaid beneficiaries, and dual eligibles. So the government is right to address them through ACOs and the like.

      But, Marmor and Oberlander are right. ACOs aren’t the holy grail by any means. Our system is going to take much stronger medicine to fix, and I would frankly argue that government is one of the only players that can make it work.

      http://jama.ama-assn.org/content/early/2012/03/12/jama.2012.362.full#ref-3