Public Learning about ACOs

"Culture beats strategy every time" is a truism in management consultation. The Accountable Care Organization concept is excellent strategy, but it won't get anywhere if our health system culture doesn't support it.

This morning I was happy to see a front page article in the New York Times about how Advocate Health Care is developing its ACO. The article is clear and informative. But the amateur medical anthropologist in me was struck by what the language reveals about the cultural context within which ACOs will thrive or crash and burn. In what follows, snippets from the article are in italics, followed by my editorial comments. I've highlighted key phrases - all of the emphases are mine:

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

In recent years I've been careful to shovel snow slowly and not to overload the shovel. If I was one of Dr. Stuck's patients I would have appreciated a call from the nurse. But note the assumption that less care is likely to be worse. As a physician who practiced for 43 years my default view is that less is better/more is worse. Many of my colleagues think the same way. ACOs won't succeed unless we can nudge the wider public into understanding that "more" does not equal "better" and "less" is often an improvement!

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

Insofar as the kind of integrated care ACOs are designed to promote is the right way to deliver care, the changed payment structure is removing a barrier to doing the right thing, not "incentivizing" us like rats in a maze. I don't think I'm alone in finding all the talk about "incentivizing physicians" to collaborate with their patients and colleagues offputting. And if I were a naive patient I'd be suspicious of care that my doctor had to be "incentivized" to provide!

“It’s hard to imagine that you could start from scratch and do this and be successful in three years," said Dr. Lee Sacks, Advocate’s chief medical officer, noting that other systems may find it far harder to flip the traditional fee-for-services system on its head. “We had a running head-start going back to 1995.”

The organizations that joined in 1995 to create Advocate have a 100 year history of faith-based health care. As a non-Christian I found the Advocate mission inspiring. I would be proud to practice with colleagues who shared the values Advocate promulgates. I wish the article had taken the following great quote from Dr. Sacks that I found on the Advocate website:

"There is just a special feeling throughout Advocate Health Care. We regularly recognize those who exemplify our values of compassion, equality, excellence, partnership and stewardship, even though many of them would say that they were just doing their job.”

A piece of cheese at the end of a maze isn't what "incentivizes" health professionals - it's the privilege of being part of a caring profession whose values go back for millennia! The admirable clinicians Dr. Sacks is talking about would be stunned to be told that their comportment reflected economic incentives, not personal mission!

In some ways, accountable care resembles earlier efforts to control medical spending, including the health maintenance organizations that proliferated in the 1980s but fell out of favor, in part because they severely limited patients’ choices. But accountable care differs by giving doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services.

This snippet tip toes towards getting the culture issue right, but it still misses the crucial point. Capitated payments facilitate investment in programs (and not just for prevention) that are not paid for in our cockeyed fee-for-service/widget-rewarding payment system. But that's not what gives doctors a "reason" to invest. The reason is that it's the right thing to do in light of a mission that even many athiest clinicians regard as "sacred."

So far, Advocate has achieved a small but significant savings of about 2 percent below projected costs, Blue Cross Blue Shield said, but it is not clear whether it can continue to make progress. Already, some Advocate hospital chiefs have expressed fears over losing revenue and warned about the threat to their financial performance. Doctors fret that their incomes may suffer. “We’re doing it because it’s the right thing to do for patients,” said Dr. Stuck, the Advocate family physician. “We’re not making more money.”

Dr. Stuck's point about doing the right thing speaks for itself!

“You’re trying to overlay a payment design onto a benefit model that allows a patient to go anywhere he wants,” said Steve Hamman of Blue Cross Blue Shield, noting that patients can undermine the advantages of the new approach if they ignore the advice or insist on unnecessary tests and procedures. “We can talk all we want about provider accountability and how important that is. But there is a measure of patient accountability that is critical as well.”

For readers who aren't familiar with the ins and outs of the ACO concept, this paragraph is referring to the fact that Medicare beneficiaries who are receiving their care from an ACO aren't "locked in" to the ACO network. If Dr. Stuck's patients want to go to the Mayo Clinic they can do so. This is likely to create clinical, economic and ethical challenges for ACOs. What if the Mayo Clinic does knee replacements better than the ACO? Do we have to refer patients "out"? What are the acceptable ways for ACOs to try to keep patients "in network"? And, most important, how do we engage patients and the public in seeing stewardship of shared resources as a societal imperative they share responsibility for?

We Yanks believe in magic bullets. That's why we have so many drugs in our medicine cabinets and drones in the sky. ACOs, alas, will not magically solve our health "system's" problems of quality and cost. The ACO is a good concept, but it won't thrive without a supportive culture. The otherwise excellent article in the New York Times shows how far we have to go to develop the culture we need!

(See here, here, and here for posts that discuss related aspects of the ACO concept.)