What It’s Like to Work in an ACO
This is Caroline Poplin, writing at the Health Affairs Blog:
I am a Board-certified general internist. I worked for many years for…an Accountable Care Organization. It was factory work: we were interchangeable cogs in a vast machine. The people who saw patients, especially “primary care providers” like me, were at the base of the pyramid and the bottom of the pecking order.
The future is clear. The management of the ACO — professional administrators, and physicians who see few if any patients — will schedule every moment of every primary provider’s day, critique every decision, continually scrutinize and evaluate every aspect of one’s practice. At my ACO, yes, we were on teams, but given no time to communicate with one another. We were forced to complete clunky electronic records we had no time to read. Despite years of training and experience, we had no input to the system that controlled our lives. We were not respected as professionals. It was demoralizing.
The health policy elite appears to have concluded that the crux of the problem is primary care practitioners, internists included, who are largely ignorant, lazy, and indifferent to their patients’ welfare, and oppose change of any kind. We do not know or care that a diabetic’s hemoglobin A1C should be below 7.
Therefore, we need tight supervision, complex systems of financial incentives and penalties, and frequent “feedback” about our deficiencies. We need electronic records to remind us that our female patients are due for mammograms, that we should advise smokers to quit. And we must reach our goals efficiently, using the minimum number of those expensive tests, and managing large panels of patients. (So we can’t spend much time with anyone.)
Hey Doc,
Welcome to the real world. We all suffer from these work conditions.
I’ve heard of ACOs referred to as HMOs on steroids. I realize there are some differences that separate the two forms of medical practice. But it’s somewhat indicative that the entity that the organization will be accountable to is the payer — just like in managed care.
Sounds horrible. Who will want to become a doctor if this is what they have to look forward to?
From that same physician’s post:
“From my vantage point, the two principal drivers of cost in our system are the insurance industry and excessive expensive technology. The insurance industry – which will no longer be allowed to manage risk — cannot manage care, and manages cost by requiring discounts from providers, which the companies pocket. We should pay insurers for processing claims, period.
Also, we have disproportionate incentives in our system for ever-costlier technology, particularly specialty procedures requiring high-tech equipment, as well as expensive imaging, tests and pharmaceuticals. Yes, there is competition, but rarely on price, since manufacturers are reimbursed for whatever they charge.
Nevertheless, health care reformers have largely ignored insurers and manufacturers, trusting, without much evidence, to future market competition. Instead, the policy elite has targeted primary care. They believe it is poor. We do not work hard enough to keep our patients healthy, we neglect important preventive measures, and our patients therefore develop costly avoidable illnesses and require too many expensive hospital admissions. We do not coordinate with others.”
Administrative costs including all insurance plans costs consume 7% of every health care dollar. If we spend 50% more per capita than the next highest country, eliminating insurance will not “get us there”.
Clearly there was a lot in PPACA that impacted insurance (i.e. no pre-existing conditions, caps on Med Loss Ratio etc.)
I wholeheartedly agree with her that we need a strong primary care base. I also agree that technology is a significant cost driver. I’m not convinced ACO’s are the solution but someone or something that manages the patient across the continuum is vitally important. That will likely include someone who doesn’t do direct patient care but monitors/manages high segments of the population across the continuum. I can see how this physician might see this as being “part of a machine” but I’m assuming she’s not interested in “managing” the orthopedic surgeon who’s seeing her patient in the hospital and what to repeat the MRI she ordered a month ago in preparation for a “unlikely to succeed” lumbar fusion.
high segments of the population should read “high RISK segments of the population”
I’m with Nancy. Why would anyone want to become a doctor?
It gives me the shivers.
I like to think of my doctor as someone who has the time to talk with me about my health, not someone who needs to squeeze in 4 more appointments before lunch.
It makes me want to have enough money so that I can pay cash for a full visit.