Shared Decision-Making is a Two-Way Street

There is one word in ACO that stands out to me – Accountability. Physicians are held to be accountable for coordinated patient care. Likewise, patients must be equally accountable for their own health and personal decisions. The success of our future ACOs may depend upon the mutual interplay between these two circumstances. Negligence on either side will necessarily result in failure. The effort to reduce health care costs starts and ends with the patient – under the guidance and support of a focused and committed family physician.

Education: Simple education – the distribution of information and materials – will not be sufficient. Education is useless without empowerment. Even the greatest teacher will struggle to connect with a lackluster and disengaging lesson plan. Patients must become owners of their own health and outcomes must be linked as much to medical care, as personal choice. Presently, the Institute of Medicine is working to develop guidance for just such an educational venture.

As it stands, CMS has mandated that all marketing of ACOs must be approved by their internal office. Considering the, as of yet, purposefully vague definitions of ACOs – this is a misstep. In commentary to CMS head Donald Berwick, the AMA offered that, “The requirement that CMS approve all ACO marketing materials is an unprecedented, unnecessary, inappropriate, and unworkable requirement.” Wow. That is harsh and bold language. But, I believe that speaks to just how important it is that robust patient education be featured on the nature of their role within ACOs.

Think of shared-accountability as an analogy to a car owner. Most patients aren’t necessarily the best drivers or caretakers of their own car. Everyone that owns a car must get some regular maintenance, inspections, and repairs – this keeps the automobile running well (hopefully). The provider of these services is usually a specialist in that area of car care. However, between these visits, it is up to the owner to ensure the car is maintained. It would be ludicrous if someone were to suggest putting water in the gas tank – yet Americans struggle coming to terms with the right type of fuel to keep their own bodies running and energetic.

Some cars look nice, others are maintained well – and these are always perceived as reflections on the owner. No one looks to the Jiffy Lube guy that changed the oil as being responsible for the well-tuned car. He is certainly an important, and necessary part of the process. But it is the owner’s responsibility to see through the spectrum of car and maintenance. Why, then, do we often view health care and our own bodies in such a different light? Why can’t a physician be viewed as a specialist mechanic that is ready for a quick tune-up, or even an overhaul every once in a while?

At any rate, I certainly understand and appreciate that our bodies are much different from our cars. However, I do believe that the relationships and care can be viewed in parallel. Doctors can teach us how to drive our cars - perhaps even read us the owners manual – but then hand over the keys and let us drive solo for awhile. That is true accountability.

Take the Accountability out of ACOs, and the Care Organization will falter. But, this accountability falls as much on the role of the provider, as it does the patient. Be vigilant that our patient population not fall into complacency, or expect anything less than a working and actively cooperative relationship with their family physicians.

Do ACOs Stack the Deck Against Private Practice Family Medicine?

ACOs have been shopped as possessing flexible application along the spectrum of clinical practice. Indeed, comments by CMS administrators have explicitly contended that the model was created to allow all physician practice groups – large to small – to have the opportunity to join in the shared savings program. However, once you dig into the regulations behind the rhetoric, it quickly becomes apparent that small private practice is meant to quickly sink, and private practice in general may barely be able to swim. It is beyond clear that the specifics of the ACO rules and regulations are outside of the scope of outpatient medicine, if not exclusionary to the private practice setting altogether.

1) Start-Up Cost

The cost of starting an ACO is the first preventive hurdle – and it is quite a big hill. While CMS conservatively proposed an estimated cost between $1,700,000 - $1,800,000, the American Hospital Association (AHA) sees it more in the range of $5,315,00 - $12,000,000. And those are just estimated start-up costs, they do not take into account annual maintenance requirements. Needless to say, this is well beyond the scope of most private practice settings.

Robert Jeibenluft recently suggested in the New England Journal of Medicine that, “provider networks that do not achieve meaningful clinical integration will probably not receive shared savings from Medicare, and most will ultimately fail”1

2) Quality Measure Reporting

ACOs will be required to measure and report along 65 specific quality metrics. This is an all-or-nothing approach, and each ACO has no flexibility in reporting. Most importantly, there is some concern that it will be impossible to meet all 65 requirements outside of the hospital setting. For example, among the discussed quality measures to report include hospital readmission numbers and assessment of the nine hospital-acquired conditions. How does a large scale family practice setting adjust to these requirements?

A flood of comments were submitted to CMS regarding these concerns. While the regulations are still a product of the proposed rule, it is to be seen how CMS will respond. At this stage in the game, awareness is fundamental. While the ACO model has been marketed well from a national standpoint – and it is gaining traction and popularity – it is important to recognize this is not necessarily an all-inclusive or all-applicable solution. Sure, the big hospitals have the chance to buy into the shared-savings program. But, let’s just hope it doesn’t drive out the little guy at the heart of medicine – the private practice family physician.

1. Leibenluft, Robert F. J.D. (2011) ACOs and the Enforcement of Fraud, Abuse, and Antitrust Laws. New England Journal of Medicine, 364: 199-101.

An Appetite for Authority: Psychological Subtleties of Choosing a Specialty

I recently had an interesting conversation with three fellow medical students over a jar of nutella. Two were MS IVs training at a major academic medical center (one budding peds oncologist, one future family physician), and the third was a canadian medical student. I am an osteopathic medical student comitted to pursuing primary care. The conversation started with romantic pursuits, Harry Potter, what to dip into the nutella, but soon evolved into a dynamic discussion about medical specialization, and why we do choose to do it.

Many people believe that the temptation to super-specialize is driven solely by salary…specialties pay more than primary care; they get you out of debt quicker and may allow for a cushier lifestyle. These are undoubtedly key factors for many students choosing a career path in medicine. However, money is an easy scapegoat. When salary is taken out of the equation, much more complex issues of personal investment, ego, and authority begin to surface.

The Canadian medical student in my nutella conversation was quick to remind us that our neighbors to the north don’t pay specialists much more than primary care physicians. Yet, in her view, young Canadian doctors still overwhelmingly prefer to specialize. People want to be experts. It's human nature. The pride that comes with knowing you could be the leading authority on something, and that people would come from all over the world (or all over the hospital) to hear your opinon is incredibly enticing to students. The high salary that specialists get in America is icing on a cake that already looks deliciously prestigious.

As we overdosed on chocolate hazelnut and the jar became pretty unappetizing, our conversation shifted from what’s enticing about specialties to the other side of the coin – what psychological factors turn students off of primary care. The future pediatric oncologist hit the nail on the head. She was telling us about her current sub-internship, working under general pediatricians on complex cases. Each of her patients saw a minimum of seven consults, sometimes up to nine or ten. In most cases, her attending knew exactly what the endocrine guy or the genetics department was going to say. Even as a medical student, she could predict how these consults were going to go, and yet, the culture of a medical center with limitless resources is to cover all bases, gather as many cooks into the kitchen as possible. It made the generalist’s job seem a less important. Even though he was supposed to have the final say on the treatment plan, my friend described a shifted power dynamic that made her attending the low man on the totem pole, a triaging traffic cop. “This is why I’m glad I want to specialize,” she explained. She didn’t work this hard to not be the authority on anything.

Primary care is not for everyone. This friend is going to be a fantastic pediatric specialist, and a caring physician. It would be incredibly short-sighted for me to claim that all students who choose to specialize are motivated by pride and ego. But it would also be naïve to discount these factors in ourselves. Choosing a field of medicine is a complex process that is ideally driven by geunine interest and passion, but often heavily affected by financial and lifestyle concerns, as well as the desire to validate the years of work we have put in to achieve our goals. There is nothing wrong with wanting to practice at a prestigious institution, garner respect from colleagues and be valued as a prominent physician. From time to time, however, it is important to step back and ask ourselves how much the desire to impress others is affecting the choices we make. A primary care physician might never be world’s leading expert on nutella allergies, but family doctors are the authority on their patients. The best ones take ownership of this more subtle authority, even in a kitchen full of cooks.