The Moral Dilemma of Accountable Care Organization Participation
The latest incarnation of managed care organizations are the Accountable Care Organizations (ACO) which are an important part of the Patient Protection and Affordable Care Act (PPACA). ACO’s promise to save the government billions of dollars in healthcare outlays by supposedly decreasing the amount of unnecessary medical care provided for the patient. The assumption is that there are billions of dollars of unnecessary medical treatment billed to the governmental payers- Medicare and Medicaid
The first go round with managed care- the Preferred Provider Organizations PPO’s and Health Maintenance Organizations HMO’s of the 1980’s were a strictly financial decision. How much were the healthcare providers willing to discount their fees for an increased amount of patients? The doctor was able to make this decision based on the numbers. While it was frustrating to discount fees, at least the doctor could make the decision to discount their fees, and possibly increasing overall income, without compromising patient care.
ACO’s, the current concept of managed care organizations not only require doctors to reduce fees, but also intrude into the amount of healthcare that the patient receives. ACO’s often set the fee structure so low that it costs the doctor or hospital to perform the procedure. ACO’s may also completely disapprove or disallow certain diagnostic or therapeutic procedures that the doctor deems necessary for the patient. The contract with the ACO will usually contain language which prohibits the healthcare provider from billing the patient for any procedure that has been disallowed, or for any co-payment. So if you, as the doctor, determine that a certain procedure or treatment is necessary for the patient, you must provide the care free of charge.
The only reason for an ACO’s existence is to reduce the cost of medical treatment. The only way they can do this is to reduce medical treatment allowed to be provided to the patient. There is no consideration for the well being of the patient. I have never been asked by a managed care organization to take more x-rays, or provide more rehab for a patient. Has anyone out there ever had a request to do so?
The government tells the public that ACO’s will save healthcare dollars by decreasing fraud and waste within the system. The assumption that there are billions of dollars of waste or fraud in the system is incorrect, in my opinion. But be that as it may, by adding another layer of oversight, the ACO must cut even more in medical treatment costs to pay for this wasted layer of management. This is the government’s way of setting up the healthcare providers as the fall guys when healthcare is decreased under the PPACA.
The moral dilemma comes when you, as the provider, determine that your patient requires a procedure that is denied by the ACO. Do you provide the treatment, even if it costs you money to do so? Also at issue is the question: “At what point, and who becomes responsible for any malpractice liability that results from the procedure not being performed? My guess would be the treating healthcare provider, as I’m sure that the PPACA protects the ACO from any liability, though I have not the entire 1300 page law.
The only way to resist this intrusion into the doctor-patient relationship is to refuse to participate in the process. If the entire healthcare provider field refuses to enroll in the ACO’s or any other type of managed care organizations, such as Medical Homes, then the entire concept will be unworkable. Signing up for networks that cut fees and do not allow the doctor to provide necessary treatment for patients has a definition attached to it.
Remember the story by Winston Churchill about the man who asked a lady if she would sleep with him for a million pounds. She replied that she would. The man then asked her if she would sleep with him for 20 pounds. She was shocked, “What kind of woman do you think that I am?” she retorted. He replied, “We already determined that. Now we are just haggling over the price.”
If we allow any ACO to determine what type of care our patients require, or how much, we are no different than the woman in Churchill’s story.
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Thursday, 06 October 2011
Disappointed that you have not read the regulations.
I think we can agree health care continues to be niether patient or doctor friendly and increasing expensive.
PPOs have proven to be very unsuccessful selling themsleves as HMO lite. Some of the most successful HMOs have been physician led Marshfield, Dean, Harvard, health Partners Mpls or consumer led Kaiser, Group health Cooperative. these organizations along with Mayo, Cleveland Clinic and others laid the groundwork for early care management principles and in some cases integrated care and reimbursement so these organizations benefited from thier own improvements in quality with additional savings shared back to the sponsoring entity. PPOs did just the opposite.
ACOs are only going to dictate care if doctors let them and this is the time for physicians to lead this change and pay themselves for taking waste out of a system gone wrong. Physicians are the focus of the Medicare Shared Savings and Pioneer program.
The problem is everyone is waiting for the government and now the private insurers to take this over just as they had in the HMO evolution where suddenly insurance companies douped the doctors and took all the savings and put it in thier pocket.That is how PPOs got started and they were NOT the first modle of managed care HMOs were. Physicians, with rare exception described above, stood by and let this happen and it WILL happen again if the physicians stand on the sidelines. That is the moral imperative ! Physicians and only physicians can make this important and vital change happen in the delivery of care. We are looking for leadership from the communities not a treatise on how its hopeless.
Wednesday, 05 October 2011
Linda Seim, DC
We are between a rock and a hard place. All patients think that their insurance should pay for the care they think they need. All insurance companies want to keep the premiums and not pay claims so their shareholders will be happy. Most doctors want only what is best for their patients. I can honestly say that there are several insurance companies that pay me less than my cost however, if you opt out, the patients will go somewhere else. I don't have any answers but after 37 years in practice, I make less now than I did when I started when there was no insurance for chiropractic care. The best part was that the patient and the doctor decided what care was necessary and the patient paid the doctor. There was no middle management that is paid more than the doctor and we didn't have to have two full time staff to file insurance and follow up on mistakes plus I didn't have reams of paperwork to fill out to try and justify my small contracted rate for services. When you are paid as little $15.60 for an adjustment, as little as $11 for two x-rays, and $36 for a new patient complete exam, you have to love what you do because you aren't in it for the money.
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