"An ACO will not limit patient choice," said Dr. Don Berwick, who heads the Medicare and Medicaid programs.
http://www.latimes.com/health/healthcare/la-na-health-reform-20110401,0,7456195.storyRemember
capitation? Back in the early 1990s it was all the rage. Encourage physicians, hospitals, medical groups and other providers to accept a flat fee for providing all the health care for their patients. It was supposed to encourage doctors to become more cost effective and discourage them from doing unnecessary tests. If the doctor knew he was only going to get $100/month for treating Sally, then there was no way he would order an unnecessary MRI, which might use up a year’s budget in a matter of minutes, right?
Wrong. Doctors----and hospitals and all other health care providers in this country---are required to meet a standard of care for all their patients. That means every women (with insurance) who develops a breast lump gets a mammogram and a biopsy, even though most of the lumps will be benign. The jury in a malpractice lawsuit, the state medical review board and the public at large will not nod their heads and murmur “Yeah, I can understand why the doctor didn’t order a biopsy in this case. The patient picked that cheap ass insurance plan that wouldn’t cover the costs. So now she has metastatic breast cancer. Sucks to be her.” No, the jury, the board and the public will nail that doctor to a cross.
Plus, if you are a provider who went into medicine because you want to help people and save lives, it goes against the grain to let them die, because there is not enough money in your bank account to save them. Every health care provider knows the awful feeling of treating folks who do not have insurance and having to watch them waste away because they can not get the 1) coronary bypass surgery 2) bone marrow transplant, 3) (insert expensive medical procedure of your choice) that they need. Under this new plan, doctors may have to choose between watching a patient die and closing their practice because the treatment has left them bankrupt.
Before you mention stop loss insurance, yes, I know that it exists, and it will help if one patient out of 5000 develops an extremely rare illness that costs millions to treat. It will not make much of a dent, if your practice happens to be full of diabetic patients in need of retinal laser surgery.
I can just hear the good folks at Medicare saying "Only bad doctors let their patients develop retinopathy. They should be punished." This might be true if we all saw the same doctor from the moment we are born until the day we die. However, Americans switch providers frequently. And, under a capitated system, they will find themselves changing doctors even more often---sometimes when they do not want to do so.
Here is what will happen if Medicare goes to a fully capitated model. I know, because I have seen it happen before with the HMOs in the 90s:Physicians will turn away the sickest patients. Why? Because Henry, who has heart failure, will almost certainly end up costing Medicare a few hundred thousand dollars over the next few years. That’s chump change for Medicare. It is the whole budget for a single physician. The doctor will not say “Sorry, I can not treat you. You will cost too much money.” No, he will say “Sorry, I am not trained to handle your particular medical problem. But Doctor So-and-so down the street---he has just what you need.”
No problem, says Health Secretary Sebelius. Doctors will form large groups with hospitals and specialty care providers. They will accept a flat fee per patient for many thousands of Medicare recipient. That will allow them to absorb the costs of the sick patients and everyone will live happily ever after.
Health Secretary Sebelius does not know many medical directors. If she did, she would understand that their job is to produce the maximum revenue possible for their physician group/hospital/surgical specialty clinic. These are the folks that will decide what kinds of patients they want their providers to treat. And under capitation, that will mean cherry picking the healthy. So….
A profitable medical group will not offer dialysis. It will not have a neurosurgeon at its hospitals which means all bad trauma cases get sent elsewhere. Since it will not have a neo-natal ICU for preemies, it will be able to send high risk obstetrics cases (some young folks have Medicare) to other hospitals, too. It will absolutely positively not have any clinics or providers in minority areas, since minorities and the poor tend to suffer more health problems than affluent seniors. It will recruit new patients at marathons, not at nursing homes. It will have an employee whose only job is to identify "high utilizers" (i.e. sick folks, in lay jargon) and figure out ways to get them to go elsewhere for their health care without violating the letter of federal law.
Imagine what happens to Medicare when a few behemoth medical groups select their healthier than average patient panels. They start getting more money per person than they spend on health care. The extra cash goes into the pockets of doctors, hospital execs and shareholders. The other health care providers, the ones in small groups and in public hospitals that treat mostly the poor will find themselves in a deep financial hole trying to take care of the sickest of the sick with insufficient Medicare funds to cover their costs. Slowly, those doctors willing to treat sick elderly will close their offices—or stop accepting Medicare. Chronically ill seniors will find their options limited. Eventually, they will have to go to the local county hospital for care, because all the private doctors in their community will be getting rich taking care of seniors who are never sick. The behemoths will use some of that extra revenue to lobby the administration and Congress to make their own reimbursement for doing nothing even better. (“See how healthy we keep our patients? We deserve a reward.”) Doctors who actually try to do their job will be stigmatized as “spendthrift”. And no one can stigmatize a health care provider the way the federal government can.
If you want to see Grandma pushed from doctor to doctor, because no one wants to get stuck with the cost of colon cancer surgery, then send your letters of support to the White House. If you believe that the sickest folks deserve more not less care, then maybe you should send letters suggesting some other way to save money---like investing in public health and disease prevention, so seniors reach retirement age without so much chronic illness.
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