ACOs , PCMHs what are they and how do they affect your future as a doctor or patient? Both terms refer to organizations of health care providers who agree to provide health care services to a population for a fixed fee with the new innovation of cost and service monitoring provided by EMR and other tools. The gatekeeper MD model, that failed to control cost in the Clinton era, is again being reincranated as a new financial savior. In addition, physician’s fees may be adjusted by their “performance ratings” as determined by the ACO. It is a drifting away from fee for service to fee for “outcomes” based upon a standard set by the ACO and often defined as “evidence based” medical care. If it sounds like and HMO, with capitated fees, and more regulation of what a doctor may and may not do as result of bureaucratic oversight, well that might not be too far off.
What is the cost issue? Health care in America did cost nearly $2.7 trillion in 2010—$9,000 per person—a $200 billion increase over 2011. $763 billion of this is for Medicare and Medicaid alone, which is over eight times the federal spending for education. Medicare and Medicaid costs have now squeezed out Social Security and defense as the number one expenditure in the federal budget, consuming 21 percent of President Obama’s 2011 suggested outlay of $3.5 trillion….. don’t know about you but to me these numbers are meaningless other than when you tell me they cost me $9,000 / year!
On the other hand there are opportunities as the system is ripe for innovation and the birth of creative organizations. What are the issues that need to be addressed for cost containment? Many are difficult areas upon which to tread, such as the last years of life. Dr. Jonathan Bergman of the University of California in Los Angeles, an author of a report on the costs of these last years medical “heroric” efforts had this to share: “We end up spending about a third of our overall health care resources in the last year of life,” Bergman said. “It represents a huge avenue for improvement.” To deal with these issues, ACOs may need to trade quality of end of life for minuscule possibilities of extended life. But lets skip this important but lengthy issue (in this article) for the one we may have more control over without huge public, religious and emotional debate. Real Accountable Care! Not just a new name for HMO’s.
Real Accountable Care should mean not just that a physician is accountable but that the whole system is accountable. Consider “Insurance companies” as needing reform as much as healthcare. Consider Bill McGuire, CEO of UHC, who in 2006 left with a bonus of 1.6 BILLION DOLLARS (stock options). We might assume someone paid for this in terms of lost benefits to patients. Again not an issue you or I will change but in the same vein what about the patients taking responsibility, being accountable? Smokers should pay higher premiums as should those who are obese and those who make no effort to be physically fit. Patient’s who, when repeatedly are educated by their doctors about needed diet and lifestyle changes, and make no effort should also be responsible. A system that does not reward efforts with lower fees, is bound to fail!
As optometrists we have a unique opportunity to help meet the Holistic needs of the new health care paradigm. Most of us are already taking BPs, body weight, asking about alcohol and smoking. This is being more holistic. In addition we also have the opportunity of monitoring general health via retina imaging. Retina imaging will give the PCP feedback as to the success of his/her efforts in patient health management. PCPS who do so are rated better receive higher reimbursements.
How can this save an ACO or PCMH money and why is it needed? It has been reported that good teamwork between a PCP and an Optometrist monitoring patient systemic health via retina imaging can save an ACO $6,000 / patient. What is needed to make this paradigm even more powerful is not just communication between doctors but Accountable patients too!
For example, the cooperative effort between PCPs and Optometrists at diagnosing early arteriolarsclerosis and treating it is a big step but patients cannot expect the system to give them a quick fix in the form of a pill! This mirage of past medicine, and pharmaceutical slight of hand, must evaporate with the sunshine of the new ACO day. In my own practice I have stressed retina imaging and patient education as a focus of our medical care. Over 9 years since we began offering holistic retina screenings we have literally saved hundreds of lives by preventing strokes, heart attacks and diabetic blindness. Many of you have done so too! The most propounding difficulty however is patient cooperation. How many of you have said to a patient, you need to cut your carbs significantly to avoid diabetes only to be told “Doc, I am Italian, to give up pasta, pizza and good Italian bread would be worse then death! Besides Doc, I am bullet proof! I take Mevacor.” Even the pharmaceutical TV ads for the drugs say “with diet, exercise and Meva###, many patients show less……..blah, blah, blah… ” In an accountable care age, with projection of health care causing national bankruptcy, everyone must be accountable. But how?
More and more of us are providing patients with literature about diet, exercise, weight loss, and sources for counselling, especially when it comes to smoking. Yet, patients are not held responsible other than by early death. One thing we have found very helpful is getting a patient to read a health newsletter that is free! If you think about it, all our decisions are based on the media and social relationships we are part of, our “data income stream and programming” in computer lingo. If a patient adds a new information source that reaches them regularly, they frequently will modify their behavior to some extent. I do not have the time to write a newsletter of this proportion but I “plug” them into one I like from and MD. Pick yours and recommend it! I refer patients to Mercola.com. It has been life changing for many of them. I also have my patient education literature published on the Internet and I send them literature as an email link to my free booklet. This too has worked well. Being able to download and read my materials on their smartphone or other device has been life changing. One patient lost 100 lbs in one year after we talked and he read my literature. His stage II hardening of the arteries totally VANISHED in just one year! He also went to the gym 4 days a week too! A few words not to be missed here is “after we talked.” Reasonable fees are needed to give doctors of all types time to talk with their patients. It has a lot more impact coming from a doctor than a tech who has memorized a script.
It would be nice if we could reach everyone this effectively but it is not so. There is a need for a financial responsibility taken not just by the doctor, the hospitals and the ACOs but by the patients too. Patients must and can be monitored for compliance by our EMR records just as PCPS may be monitored by successful outcome scores. Those that do not make an effort and show no progress, must bear the burden of their choices.
As the new health care paradigm evolves, we must seek a voice in ACOs and PCMHs. We will have a voice if we are BIG ENOUGH and UNITED ENOUGH to matter. This is the goal of the NYIPA. Quality patient outcomes through inclusion in the new health care paradigm by the Power and Size of a Unified New York State Optometry!
Join the NYIPA, make your voice heard! Make a difference by working with your colleagues to do something you never dreamed possible, save thousands of lives though a team effort!