As a result of the federal government’s push towards a value-based healthcare system, physicians and other providers are under increasing pressure to find ways to improve patient health outcomes and reduce costs. One way the feds seek to address these goals is through accountable care organizations (ACOs); in January, the Obama administration said it wants 30 percent of traditional Medicare fee-for-service payments tied to a quality-driven, alternative payment model, such as an ACO.
Nonetheless, research shows that physicians remain uncertain about the structure and effectiveness of these paradigms. Prior to the U.S. Department of Health and Human Services’ (HHS) aforementioned announcement regarding value-based care, the 2014 Physicians Foundation Biennial Physician Survey released last December found that while physicians are informed about ACOs, they are still not convinced of their effectiveness. The survey from the Foundation, a nonprofit organization focused on supporting physicians in sustaining their medical practices and navigating healthcare reform, found that: a majority of physicians (52 percent) do not participate in ACOs; more than a third (36 percent) of physicians believe ACOs are unlikely to increase quality and decrease costs; 31 percent of physicians are unsure about the structure or purpose of ACOs; and 19 percent of physicians believe the quality/cost gains will not justify organizational cost effort.
According to Joseph Valenti, M.D., board member of the Foundation and a practicing obstetrician/ gynecologist at the Denton, Tx.-based Caring for Women practice, plenty of physicians are having their fair share of problems with the process that is behind ACO arrangements, and on a larger scale, the entire shift to value-based care. Valenti, who has 13 years experience in the private practice arena, recently spoke with HCI Associate Editor Rajiv Leventhal about these physician challenges, and what he thinks can be done to better the system. Below are excerpts of that interview.
Why are physicians uncertain about ACOs?
I think that a lot of physicians are not completely convinced that the data is out there to demonstrate that they could potentially develop the savings necessary, and prevent hospital admissions and readmissions. Much of the healthcare spending that is extreme right now is in hospitals, not clinician offices, so the concern is, can you keep this person out of the hospital? Also in terms of Medicare ACOs, you’re going to be assigned 5,000 patients at least, and they could be the sickest patients out there, so there is no guarantee that you can make them well enough and be assured that they don’t need to come back to the hospital. So maybe you can’t demonstrate shared savings. And the ACO stats prove this; one-third of them are working, one-third are breaking even; and one-third are leaving the program.
Joseph Valenti, M.D.
How do you suggest the process improve?
Well, I don’t think that ACOs are the only way to increase quality and decrease costs. Many of those same things can be accomplished by an MSO (management services organization) with negotiation with an insurance company—without the ACO component. As far as ACOs in general, it will be hard to entice people to get people involved in one especially if there will be a potential downside. When they structured these things, they had different tiers, and the highest shared savings also involves some loss of money if you go the other way, and that’s a problem.
I think one of the other problems is that because when the government mandated electronic medical records (EMRs), they didn’t mandate that they would be able to communicate with each other. This EMR transition has been really difficult for a lot of people; our survey verifies that many are unhappy with them. They like their ability to access information from anywhere, but the transition over is difficult. They’re not happy that it doesn’t communicate with other doctor or that the informatics doesn’t match exactly match what insurance companies and Medicare want with regards to reporting. As a result, many practices can’t even stay open. ACOs by their very nature involve consolidation, and not everyone is thrilled with the pace of patient care and what that might mean for consolidation. So I think the difficulty is that in convincing people to go an ACO, no one has completely convinced anyone thus far that it will enhance care markedly for patients. Physicians are really uncertain about that.
What would be your pros and cons for joining an ACO?
We have never been approached to become an ACO, though I think the concern about shared savings is that if you’re already doing a really good job managing patients, and you are doing it as efficiently as you can, where is the savings going to be? People are having a hard time grappling with that. I think the savings are in hospitals, but of interest, I don’t see the hospitals getting rid of things where they get paid two to three times as much to do something in hospital as we get paid in the office. The incentives are really backwards in some ways to incentivize them to get involved, especially for those who are already practicing medicine as well as they can. Now if you have a very large group of Medicare heavy patients, and you have the ancillary help and midlevel practitioner help to follow up constantly, then you can do that. But that’s often not the case.
Another problem that the Affordable Care Act (ACA) failed to address was poverty. It doesn’t address many of the social determinants of why people are compliant or non-compliant. If patients have to choose between heating their house or buying prescription meds, what will they do? Will they be compliant with their meds? No. But do people want to be well? Yes. Do patients want to be compliant? Largely yes, but they can’t always afford to do so. Poverty is actually the largest social determinant of good health, and we are seeing that in the research we are currently doing. We spend less on the front end but more on the back end. Other countries do the opposite. ACOs address the back end, but they don’t address the front end. And that’s where a lot of the problems begin.
How has your practice’s experience with IT been?
Like all of us, we initially started on paper in 2001 when our practice started. We transitioned very early to an EMR, but that EMR company went out of business three months later, so it was money down the drain. When you get into an EMR, there is no guarantee the company will be there later. The transition also slows your practice down for six months, so it’s an enormous loss in revenue, similar to what we could be seeing with ICD-10. The second EMR we got into promised us something that it couldn’t deliver on, so we got into a lawsuit with them and ended up settling.
Now with our third EMR, GE Centricity, we are doing well on that but we just got an update for ICD-10, and you’d be amazed with how many codes are not in there, including very common ones. This is the story with EMRs—no one has compelled them to simply “come up to snuff.” The concern is that I will put my whole future in the hands of this IT system, and maybe it will work but maybe it won’t. The cost of this for us was over a quarter of a million dollars, and we’re not as satisfied as we should be given the cost. We can’t believe the number of bugs and glitches with it. There are eight providers in our group, and we do like the ability to access our EMR from anywhere when a patient calls middle of night. I wouldn’t go back to paper, even though I know a lot of doctors actually would—many have been jaded by EMRs that were not well supported and cost them a ton of money and time. I call these things unfunded mandates—things we must do but no one is funding anyone to do them.
Overall, how do you feel about the shifting of the healthcare landscape?
I’m not okay with the way it’s being done. I am okay with value-based care—excellent medical care is cost-efficient care. The more thorough you are, the more knowledge you have, the more diagnostically correct you are, the less likely you are to spend more money, the better your patients will be. We can’t control patient behavior though. Where is their responsibility? If a patient is supposed to come in and get a mammogram every year but hasn’t gotten one in 10 years, what can I do about that? I can’t make them go. You aren’t being reimbursed adequately for a lot of these patient engagement strategies, and as insurance payments keep going down and doctor’s costs in the office keep going up, how are physicians supposed to spend extra time to do those things? It’s a perverse system. From 2000-2010, Medicare payments to doctors went up 3.5 percent in 10 years. To hospitals, payments to hospitals went up 30 percent. That’s where the cost savings are supposed to be—the system is slanted towards hospitals. The ACA is largely based on keeping people out of the hospital. You’re trying to incentivize a group that is already being de-incentivized. It’s a strange way to do things.