Small wonder the first response of many of the nation's physicians to the accountable care model for reform is one of skepticism.
In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act, resulting in the biggest unfunded mandate ever passed at the federal level. Emergency departments were required to care for any patient who presented on the doorstep, but no resources were provided to back the mandate. The average emergency physician provides more than $150,000 annually in uncompensated care to patients presenting to the ED. The unfunded EMTALA mandate has resulted in the wholesale fleeing of subspecialty physicians from on-call panels, and an on-call crisis afflicts all parts of the country. The gutting of real funding by Medicare (a trauma patient nets a mere $16 no matter the resources dedicated to care) has resulted in cost-shifting that is no longer sustainable, even by the insured.
Our contemporary health system is one of rescue care as opposed to preventive care. It is fragmented, redundant, with no inherent accountability. Our system, which rewards mistakes and complications, now consumes 16% of the gross domestic product with no abatement in the future. Inefficiencies, waste and overutilization add to this recipe for insolvency and wholesale collapse. Physicians bear witness to these faults with the current system on a daily basis. The diabetic patient who continues to smoke gets inadequate care to prevent the complications of his disease until he falls victim to a heart attack and then no holds are barred in our efforts to resuscitate him.
There is far too little effort at screening for cancer, and then 75 cents of every healthcare dollar is spent on the last six months of life, using every treatment available, even when the quality of the life being prolonged is in question. Patients receive costly diagnostics and treatments in acute-care settings only to be discharged into thin air, with little follow-up and a 20% readmission rate for the same disease within 30 days of discharge. Finally, there is one important element missing in our current system: Accountability on the part of caregivers and also on the part of patients.
The model for accountable care and the patient-centered medical home seeks to remedy much that is wrong with this system. Can physicians imagine a system where they are part of a coordinated healthcare team that knows each patient's medical problems and crafts an overall and ongoing plan for health maintenance? Patients are engaged in this new system and know their doctors' names, their medications and their overall plan of management. They know what to watch for as signs of worsening disease and take some responsibility for their own outcomes. Fragmented care gives way to an organized strategy involving healthcare teams and engagement on the part of patients.
The accountable care model has embedded in it goals that every physician ought to be able to endorse. The framework of accountable care organizations is designed to reduce costs while driving up value. Applying a popular contemporary business model (the Blue Ocean Strategy), ACOs are designed to eliminate, reduce, raise and create. Eliminate unnecessary and redundant testing, avoidable hospital readmissions, use of paper documentation and hospital-acquired infections. Reduce fragmented care, overall hospital admissions, one-on-one and face-to-face provider visits, poor health maintenance and the use of phone and fax. Raise the level of chronic-disease management, patients' engagement in their own care, home monitoring and follow-up, health promotion and preventive-care screenings. Create broad integrated networks, patient-care teams, patient registries, patient portals, virtual visits and multiple access points.
All of these elements should make sense to physicians practicing in the trenches. Of course, in terms of implementation, the devil will be in the details. Still, given that the current healthcare delivery system is on life support, standing still would not seem to be an option.
Dr. Shari Welch
Utah Emergency Physicians
Salt Lake City
Quality Matters Consulting