Recently two articles were published with seemingly contradictory information regarding the consensus opinion of doctors with respect to ACOs.
The first article, Survey: Forming an ACO Ultimately is a People Problem, published by Medical Economics, referenced a survey proclaiming that “physician alignment is the most serious obstacle” with regards to the adoption of ACOs. The article goes on to clarify the point by saying:
The problem is that physician practices and hospitals have rarely been on the same page on many issues, including patient care, costs, reimbursement, and governance. Yet they would have to work together to create an ACO without clear guidelines on who would head the organization, how risk would be shared, and how everyone would get paid.
Shortly after the above article was published, HealthcareITNews published an article titled, CMS Director Says Doctors Want ACOs. The article references a gathering of healthcare stakeholders where Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS, states that “doctors see the inefficiencies in healthcare today and are eager to try accountable care organizations.” Since the proposed regulation was released, CMS has received about 1200 comments on the on the proposal. And of those comments, Blum stated that “many doctors commented favorably.”
So which is it? Do doctors support ACOs, or not?
I think the answer lies in the point-of-view with which the doctor is analyzing the proposal. Whether a doctor is in the business for the good of their community, or the good their business, can be a hotly debated topic. But I believe it is the medical-mind versus the business-mind that creates the differing perspectives that doctors hold with regards to ACOs.
In his speech, Mr. Blum also stated that “there is a much stronger recognition than in the past” that change is required. This plays to the medical-mind perspective of the doctors. If you believe that the average doctor chose his profession to be a servant to the healthcare community, then it should follow that doctors would embrace a proposal with intentions to provide better care for the community.
However, doctors are also business owners. And if you try to apply a business case against an ACO model from a doctor’s point of view, the returns could probably be considered speculative at best. Even if the doctor already uses a Certified EHR system, the additional upfront costs for true interoperability can be substantial. On the revenue side of the business case, the shared savings payback is not forecastable. Not only must the doctor spend time on a governance committee to ensure they get their fair share of the shared savings, but the true potential savings are almost impossible to predict because there is simply not enough number-based history to confirm how much interoperability and other added efficiencies will truly save. What CEO would sign off on a large capital expense with little evidence to substantiate any predictable returns? This is generally territory for risk-taking entrepreneurs, not established business owners.
So what guidance does the ACO proposal give on increasing efficiencies?
The proposal document routinely points back to certified EHR systems, and infers that utilizing certified systems is the first step to achieving interoperability efficiencies. However, the EHR Certification Stage 1 test requirements for interoperability are at a bare minimum level. They only require the EHR to send a CCD or CCR document to a remote system via a secure protocol, which could be via e-mail. The level of interoperability required to achieve the efficiencies required for shared savings go well beyond those mandated for certification requirements.
So what is the solution?
The solution has to be one that closes the gap between the point-of-views, the medical-mind and the business-mind. To do that, solutions need to be available which provide a significant increase in efficiency and quality of care without breaking the bank upfront. The doctor who is thinking with his business-mind cannot justify the upfront costs to procure the infrastructure required for a system that supports all the IHE protocols necessary for a fully interoperable health system. There has to be a more entry-level type option for setting up a health system. A way that achieves the quality and efficiency gains with a simple approach that can then be scaled upward as the system is proved in. That would draw the medical-mind and business-mind closer together, and allow for a more consistent message that doctors really do support ACOs.