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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.