Obamacare May Alter the Doctor-Patient Relationship

This article first appeared in the Sacramento Bee

If you have health insurance through Medicare or through your employer—as the vast majority of insured Americans do—you have mostly been insulated from the tumult of the Affordable Care Act rollout.

But your turn is coming.

Embedded in Obamacare is a cost containment feature that could sweep up doctors and hospitals almost everywhere, and possibly turn traditional fee-for-service medicine into a niche practice. Nationwide, hundreds of hospitals and medical groups are planning to implement some form of it this year, and thousands more are studying it closely. An estimated 14% of the national population is already going to a doctor who is part of the initiative, and may not even know it, according to Kaiser Health News.

The feature is called Accountable Care, and it will sound somewhat familiar to those who know how Health Maintenance Organizations operate.

Under the Affordable Care Act, Medicare is taking the lead in implementing Accountable Care, with private insurers close behind. Using its huge leverage, Medicare is making deals with health care providers to reduce expensive hospital admissions and specialist care by pressing for better preventative care, and more extensive post-hospitalization follow-ups.

It is called Accountable Care because the providers will have to prove that they are keeping people healthier, as opposed to simply billing for each service provided to patients. In the Medicare deals, hospitals and doctors form Accountable Care Organizations to serve 5,000 or more clients. The ACOs must meet quality standards of care for almost three dozen ailments where preventative steps could make a big difference, from diabetes to household falls. If they can keep costs down significantly compared to earlier benchmark years, they split the savings with Medicare.

Insurance companies are eager to tap those savings as well, and are ready to spread the ACO model to employer sponsored plans. What difference will that make for workers who have avoided HMOs in those plans? Plenty.

As always happens in cost containment, choice suffers. Doctors and hospitals in integrated networks want to keep patients within those networks so they can make up in volume the money they are losing in individual fees for service. And efficient care might mean seeing somebody other than an MD, such as a physician assistant, or even a nurse practitioner to resolve some simple issues like a rash or the flu.

On the other hand, if you are part of the 1% of patients who account for a fifth of all health care spending, the Accountable Care formula is going to focus a lot of attention on you, with the goal of better health leading to fewer treatments.

If you had a fall, you may get regular home visits from a nurse practitioner to make sure you are safe and not as likely to fall again and break a hip. If you have congestive heart failure you might get a daily phone call asking you to weigh yourself, since a noticeable change in weight can be a tip that a crisis is around the corner. If you are diabetic a pharmacist may call or visit to make sure you are taking your medications, and in the right order. You might also get low-cost pedicures to avoid in-grown toenails, which can lead to infections, which in diabetes can lead to amputations.

Overall, the financial incentive for keeping people well is overtaking the financial incentive for sending them to the hospital.

CalPERS, which provides health benefits for nearly 1.4 million California public employees, has already booked millions of dollars in savings through its Integrated Health Care Models (IHM), the term the pension giant uses for its version of an ACO. Those savings are expected to grow over the next five years with expansion of CalPERS IHMs. “It is a foundational issue for us,” said Doug McKeever, its chief of health policy research.

Cedars-Sinai hospital in Los Angeles is testing a Medicare ACO and one affiliated with Blue Cross. The data flowing through those systems quickly spot doctors who order procedures at a much higher rate than their colleagues.

Daniel J. Stone, medical director of the Cedars-Sinai Medical Group, says up to a third of all procedures may be unnecessary. He believes the ACO model will spread rapidly for the same reason that commercial airplane manufacturing narrowed to two main competitors, Boeing and Airbus, with little apparent difference in service to passengers. “We are being tested by the wind tunnel of efficiency,” he says.

The promise of that wind tunnel is a healthier nation, at lower cost. But it also may alter priorities and expectations in the patient-doctor relationship. The next time you see your doctor, ask if an ACO is in both of your futures, and what it means for your care.

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