Medical choice is vital

By Horace Schneider

Cape Girardeau may be following the national trend for medical practice, but there is concern that no one knows if this model of integration is good for the patient or for the overall problem of cost. When all physicians work for one hospital there will be no competition or choice. Medicare recipients need to understand how the ACO (Accountable Care Organization) model will affect their care. Like other ill-conceived government programs the influx of taxpayer funds may allow this model to then spill over into the private sector.

Physicians do want to provide the best possible care to their patients. Business in general is more complicated today whether you sell and change tires, run a grocery store or a medical clinic. The rules of business have become more complicated over the past 20 years. The government regulations, environmental concerns, state laws and federal laws all add to the burden of work. I don't think medical care is unique in this concern.

The concept of all care being provided by one entity was tried in the past and for the great majority the public did not like the health maintenance organization (HMO) model. HMOs were based on the premise that care could be coordinated (cost savings), care could be monitored (preauthorization) and when total dollars spent was less than a particular amount those responsible for the savings could share in that savings (doctors and the HMO). The ACO has a nice ring to it, "accountable care," but it is a government sponsored HMO.

Accountable Care Organizations will remove patient choice. Centralizing all parties involved into one entity creates enormous opportunity for both control and abuse. If the center of the ACO is a hospital it is a win-win for the hospital. The ACO and its members use the hospital as the primary location for all heath care needs. If the ACO operates as CMS estimates with a cost savings (money left over equals anticipated expenses minus actual expenses) this is then shared by the hospital and the payer.

A proposed ACO based in a Minnesota hospital distributes the savings as follows:

* Payer (initially this is the government) 50 percent

* Hospital system 30 percent

* Primary care physicians 10 percent

* All remaining providers 10 percent (surgeons, all medical specialists, radiologists, etc.)

The center for Medicare estimate of $430 million in savings over three years is pie in the sky. The government also estimated in 1960 that Medicare would cost $12 billion in 1990, but it actually cost $109 billion. There is so much bureaucracy in the ACO model it is beyond comprehension (www.gpo.gov/fdsys/pkg/FR-2011-04-07/pdf/2011-7880.pdf). A few key points might be worth mentioning:

* Medicare fee for service beneficiaries (grandma) will be retroactively assigned to ACOs based on primary care utilization during a performance year.

* You can only be assigned to one ACO.

* Beneficiaries will not receive advance notice of their ACO assignment.

* An ACO must have 5,000 beneficiaries but there are exceptions.

* To be eligible to receive shared savings, the ACO must also meet certain quality standards (sounds good). These include, patient caregiver experience, care coordination, patient safety, preventive health and at-risk population/frail elderly health. I don't see anything concerning overutilization or underutilization of medical services or quality benchmarks such as post-op infections. Maybe that comes later after the savings part.

My concern is that the government will control cost by one of two methods or both: reduced fees paid and limited access.

Do I think that medical care can be improved? Yes, but it is a science that in some areas is not perfect and in many cases evidence-based medicine is controversial. The delivery and access can be improved. The focus on quality and performance is a much-needed discussion. There is overuse and underuse of medical care in several areas and I am not convinced that the ACO model will make a significant change. I feel that most patients want their doctor to work for them with as little interference for other entities as possible. Coordination of care can be accomplished with good communication and does not require a common place of employment. The free market should prevail, let the physician demonstrate quality, participate in benchmarking and compare costs, then choose your health care provider. Don't let the government make that decision for you.

Dr. H. L. Schneider Jr. is a board certified gastroenterologist working with Gastroenterology Associates since 1991 and medical director of GA Endoscopy.