Accountable Care Organizations and the Potential Upcoming Crisis in Primary Care
By Mary S LaMoreaux, CPA, CFP, PFS
Provisions in the Affordable Care Act set up a system where Medicare would pay doctors to join together to give coordinated care to patients under an Accountable Care Organization (ACO). There are many different models of Accountable Care Organizations but it usually includes a payment system that gives doctors incentives to keep patients healthy by paying doctors a flat fee for a patient, then paying a bonus for “medical cost savings.” It uses quality measures to determine if the doctor is “saving” Medicare money.
When the Accountable Care Organization (ACO) model was first conceived It was based on the theory that if you find a problem early, it will cost less to fix it. Taking care of cancer at Stage 1 is cheaper than at Stage 4. You do this by testing often and early.
The ACO system sounds like a good plan, but it has 3 basic flaws. The first flaw: on average, 75% of a person’s health care costs are encountered in the last 2 years of life. You will always have those last 2 years of life. Everyone dies. So, you are increasing longevity, which is a good thing, but this will likely not decrease costs over the long term.
The second and main problem is that there is a finite number of primary care doctors and the primary care doctor is necessary for this program to work. This reality does not cause a problem for people who already have a primary care doctor, it causes a problem for the people who do not have a primary care doctor. For instance, say you are a person who does not get sick very often. You go to urgent care when you have a sinus infection and that’s about it. You work too hard to go sit in a doctor’s office for three hours when you are not sick.
Then you start to have some stomach problems so you go to a gastroenterologist. He gives you a colonoscopy and removes a polyp that comes back with cancer on it. The gastroenterologist says you need surgery, so you call a surgeon. The surgeon says he can do the surgery but it cannot be done at a surgery center, you have to stay overnight in a hospital. The hospital requires you to have a primary care doctor sign off before they will admit you. You call the primary care doctor and he either says he is not taking any new patients or he says he can fit you in 3 to 6 months from now. I know doctors do not like this type of progression, but it is what makes sense to people who are not in the medical field, the patients. If you do not have connections to a primary care doctor, you are going to struggle.
What does this progression have to do with the ACO? The thing with an ACO is that the doctor does not get paid his bonus unless he meets the metrics. Primary care doctors don’t make a lot of money in the first place, but without the bonus, they barely pay overhead. The metrics the doctors must meet include things like making sure a certain percentage of patients get their mammogram and colonoscopy on time.
Primary care doctors are now concerned about teaching health promotion and education. These are all noble goals to promote longevity, but the system also insists that the primary care doctor correctly complete the notes in the Electronic Health Records, which means the primary care doctor spends more time looking at the computer than at the patient. The actual care of the patient, especially the patient that cannot get a primary care doctor, has been lost in this system.
The third flaw in the ACO system is that it incentives even those who have primary care doctors to visit urgent care or the hospital emergency room--because they think their primary care doctor is too busy.
Trying to get patients out of the emergency waiting room was one of the primary reasons we were told that the Affordable Care Act must be passed. However, as the primary care doctors are now too busy to see their patients, except for the 3-month or 6-month check-up, people do not think to call them when they are sick. They go to urgent care when they have the flu, and the emergency room when they think they have something worse.
I am not blaming the primary care doctor for this, I am blaming the system that has been set up by the government. Medicare likes the ACO model and has made some proposals to increase access to people in low-income and rural areas, and generally improve it, but the core problems are that there are not enough primary care doctors and they are not being used in the most efficient way.
Between the Great Resignation, and the fact that most doctors want to specialize because they can make a better living without having to work crazy hours, the system is breaking for the ordinary American who does not have or does not want a primary care doctor.
I do not see a solution to the lack of primary care doctors, but the problem must be recognized before a solution can be worked on. Preferably it will be recognized and worked on before it reaches a crisis.
Mary S LaMoreaux received her Bachelor's degree in Accounting from Marquette University in Milwaukee, WI in 1982 and became a Certified Public Accountant at that time, She became a Certified Financial Planner in 2000, and Personal Financial Specialist in 2010, Mary owns a full-service accounting firm and has worked advising doctors and their practices in Lake County, Florida for over 25 years. Mary received her Masters degree in Theology in 2018 from St. Leo University, Lake City, FL.
 | A guest post by
|
The ACO model has effectively been a disaster. The "excess payments" for keeping patients healthy have, by in large, not materialized. ACO's have all of the issues of the now-defunct (except for traditional Medicare) indemnity insurance model with no particularly notable upside.
As with almost all such flawed-from-the-beginning government overreaches to control medical care, the understanding of patient health on an individual basis (which might make it work) is completely missing -- replaced with population health measures which are completely defined by being "easy to count" and having almost nothing to do with the health of anyone. One cannot care for a population, and as von Eye has shown beautifully, knowing everything about a population tells you nothing about an individual. In the end the $$ are just reduced because that is what the government does (look back at their forced collapse of the subacute care and home nursing care sectors over the past 25 years).
Another of those "sounds good to politicians" and "rewards big players" but virtually inimical to good patient care initiatives. Part of this is the lack of PCPs, but much of this is far more structural than that.
Interestingly, and unexpectedly to me, the rise of concierge care, which is essentially primary care without the government, has been extraordinary with patients generally far happier. Someone should learn from this...but they will not.
The best thing anyone could do is stay far away from doctors. The most recent proof of this advice is the past two years of misinformation by doctors advising their patients take an ineffective and unsafe experimental biological, injecting pts with a spike priories is Frankenstein medicine and most of them knew it! Use urgent care doc in the boxes with pa’s and np’s. They are as good as a doctor if not better.