August 10, 2012: Same Song, Final Verse?
By Rob Tenery, MD on August 10, 2012
In his proposal to overhaul the country’s heath care delivery system, President Bill Clinton introduced the concept of ‘health care cooperatives.’ In theory, all citizens would be required to enroll in a regional alliance that would furnish their health care needs. Never enacted, Clinton’s massive plan died in the Congress.
The Patient Protection and Affordable Care Act (PPACA, Obamacare) is due to be implemented in 2014. Central to the new law, that is projected to give health care coverage to an additional 32 million lives, are state and regional Accountable Care Organizations (ACOs). As in Clinton’s plan, ACOs would be all-inclusive, regional healthcare delivery systems. Reportedly, half the states have already begun to study or are in the process of developing ACO models. The initial organizations are being designed to address the growing costs of the additional low income and disabled patients that are going to be covered by the expanded Medicaid program laid out in the new law.
In theory, the ACOs will be comprised of physicians, hospitals, counties and community organizations that will operate under a risk-adjusted model where global rates are based on the total patient’s care rather than for each service rendered. This reintroduces the ‘bundling’ concept that has been hotly debated in the past. Also, using the incentives, similar to those in capitated systems, the participants (doctors, hospitals, etc.) are promised their fair share of any savings squeezed out of the ACO’s budget. This model, which introduces the potential for profit, also creates a financial risk to those same participants if their projected budget is exceeded. The premise behind this concept is that those who are vested in the system are the most likely to create efficiencies to protect their own self-interests.
The problems with ‘bundling’ and the capitation systems are several: The unknown outcomes that occur in the science of medicine that can lead to un-projected cost outlays. The potential for conflict between the participants, not just for any unused funds, but for control of the ACO. Finally, and most important, the potential for less than optimal patient care.
None of these concerns are new. Scattered throughout the country, variations of capitated systems such as Kaiser/Permanente have operated similar programs with reasonable success for years. However, some of the concerns, such as loss of physician autonomy and limitation of diagnostic and therapeutic options for enrollees, have been born out. Still on average, these systems deliver health care that is up to the community standards.
Extrapolation to a much larger population segment does raise concerns. The programs currently under development now involve the expanded Medicaid population. It is likely that those individuals with significant pre-existing medical conditions and workers of companies that would rather pay the fine than provide coverage will quickly follow suit. (A recent poll of employers put that percentage at 10 percent initially).
What the designers and supporters of the ACO modes are assuming is that the efficiencies through shared information technology (electronic medical records) and economies of scale will create some of the necessary cost savings with the projected increase in covered lives. To add teeth to their premise, they have introduced both positive and negative incentives into this model.
If the ACOs become the predominant form of health care delivery there appear to be three major changes this country will most likely face:
First, the ultimate death of private health care insurance. As more and more lives move into the ACOs where the risks and costs can be supplemented with federal funds and spread out among the other patients in the system, the remainder of employers will find themselves paying much more for coverage offered through a dwindling number of insurers. Feeling the pinch of these increasing costs, more employers will opt to pay the penalty rather than the escalating premiums for their employees. Thus, they will force these employees into the ACOs. With fewer lives to cover and with increasing loss of bargaining power with the providers of health care services, the traditional insurers may well divert their interests to more profitable venues in the insurance industry. As competition dries up, control shifts to the ACOs to set rates and parameters for care--- a move toward a single payer system.
Second, is the probable death of the fee-for-service delivery model. The Medicare Payment Advisory Commission (MedPAC) was established by the Balanced Budget Act of 1997. Its primary role is to advise the Congress on issues affecting the administration of the Medicare program. The current chairman of MedPAC’s board, Glenn Hackbarth, appearing before the House Ways and Means subcommittee on June 19, testified to “make it difficult” when he was referring to applying pressure to physicians who continue in a fee-for service model. Long term, the report from the MedPAC commission wants to move the Medicare program in the direction of “the shared savings payment approach for ACOs or bundled initiatives.” (1)
Even if the ACOs take over, affluence, proximity to a provider, urgency and wait time will still create some demand for noncomplex medical services. But as medical expenses continue to rise, more and more patients will opt to forgo these conveniences. In turn, financial uncertainty from decreasing demand will force most physicians into becoming part of the ACO systems. Questions then arise as to whether contacts will allow participating entities within the system (physicians, hospital, etc.) to also treat patients who are not enrolled in the system, except for emergent conditions, and under what fee structure. Due to the financial uncertainty from a smaller patient base, most physicians will move into and be forced to comply with any dictums set down by the ACOs.
Third, and most important, the death of the independent practitioner.
Will this happen if the PPACA legislation is allowed to stand? Not at first. Since the Supreme Court has allowed the States the right to choose to not participate in the expanded Medicaid program, the ACO model of delivery will, at first, be only another choice in financing health care delivery. Additionally, the winners of the upcoming election could vote to overturn this controversial legislation.
One thing that can be predicted is that the concept behind the ACOs, the ‘health care cooperatives’ and the capitation models is not going away. Incorporating economies of scale with shared information technology into any solution is essential if this country is to meet this country’s growing health care needs.
However, without a pluralistic approach to the delivery of health care, not only do physicians relinquish control to a central authority, they and their patients become nothing more than Xs and Os on a computer printout.
References:
(1) Fiegl, C. American Medical News. July 23, 2012. P. 8.
|
|
Additional Blog Posts
Robert Mueller Finally Showed his True Colors
Stop Confusing Trump the Man with Trump the 'Force'
The College Education "Gamesmanship Racket" by Odell Brown
Where Trump Might take Us if Elected to a Second Term
They are Probably Going to get Away with It... For Now
Who Will be Steering Our Ship into the Future?
How Long Will the Kite of Obstruction Fly?
Caught in the 'Honey Fly Trap' Biden Helped Create* by Odell Brown
When Doctors Finally Said No
A 'Wag the Dog' Tale if There Ever was One
Love What Your Country Can Do for You and Ask for More* by Odell Brown
Their True Colors are Showing Through
Where do We go From Here with Our Health Care System?
The Crisis of Late Third Term Abortions
A New Push for 'Rights' from the Left * by Odell Brown
Accepting Racism because 'It was Just the Way It was'
Illegal Immigrants Could Determine Our Next President
Trump Should forget Running in 2020
Is Trump's 'Wall' about Racism?
The Democrats May Leave Him No Choice
Pretend-Conservatives Christian Politicians and Your Conservative Values * by Odell Brown
Out of Pocket 'Hush Money' ain't Illegal
The 'Old' Democrats and Donald Trump Share the Same Vision
Black Middle-class Achievement has its Best Chance with Two Parents* by Odell Brown
Voter ID May be the Only Way to Make Our Elections Honest
Did Hillary Finally Get Her Win?
Does Respect for Our Borders Matter?
What is Trump's Angle?
When Protests Turn into 'Mobs'
Kavanaugh's Accusers Could Not Pass the 'Smell Test'
It's One Big Shell Game to Them
A Civilized Civil War, For Now
How Identity Politics Ruin Decent People
Public Good versus the Greater Good
An Another Attempt at a High-Tech Lynching
It Would have been Simpler if Hillary had Won
My Football Watching is Now on Saturdays
Some Girl in Iowa
Are Today's Younger Doctors Better Physicians?
A Constitutional Convention May be the Only Chance
This Country has Lost Respect for the Office of the Presidency
Where are the 'Blue States' Taking this Country?
The Interest in Children of Illegals 'Stinks Like a Week-old Fish'
Maxine Waters is Taking Her Black Privilege too Far
Who Would Our Founders Select for the Supreme Court?
What if Trump Took a Knee?
Mueller’s Investigation is Acting Unconstitutionally
The Art of the Compromise
Betrayed by the Intelligence Community
For his Own Good, Mueller Needs to Wind It Up
Michelle Wolf: A Don Rickles She's Not
The District Court Judges are Tying Trump's Hands
Jeff Sessions' Recusal is Trump's Biggest Mistake
Meaningful Dialogue is Being Strangled Out by Corporate Sponsors
Trump Could be Moving West
School Shootings: We're Looking Past the Problem
'Big Brother' is Stepping in on Social Media
Is There a Better Way to Stop School Shootings?
'Bottom-Feeders' --- The Fourth Branch of Government
Even Rachel Maddow Should have Reason for Concern
"What Difference… Does It Make"
The Continuing Creep of Socialism
Are We Being 'Duped' about Illegals' Crime Rates?
What if Trump Ran as an Independent in 2020?
Millennials Need to Wakeup to the Big Picture
A Cancer in the Nation's Capital
They Couldn't Believe It When Trump Said 'No'!
Do They Ever Vote for the 'Greater Good' in Washington?
Bernie Sanders Won't Be the Last
It's Time for Doctors to Speak Out
Stopping 'Black Swan' Slaughter
Is Taking the Knee Blacklash or a Push for Globalism?
Maybe the 'Deplorables' Knew What They Were Doing
It's The Cover-up That Should Get Them Convicted
The Demise of the Independent Physician
President Trump Trumps Obama(care)
Does Kaepernick Have a Point?
If Not Trump, It Would Have Been Ted Cruz…or even Jeb Bush
Take a Knee, Draw the Penalty
Crossing the Aisle on Healthcare Reform is the Only Option
The Conservative Movement's Last Chance
Political Correctness is Airbrushing Our History Away
Picking Your President Blindfolded
It Took Harvey to Bring Us Together
A Republicrat Fairy Tale
Where Does the Congress Go from Here?
The Stench from the Swamp is Getting Worse
Jorge Ramos Might Take a Lesson from His Native Mexico
The 'People' Deserve 'Their Day in Court'
Which Party is 'Wagging the Dog'
The Goldwater Rule Could Come Back to Haunt Trump's Critics
The Deep State--- Possibly Watergate on Steroids
The Republicans Don't Know Whether to Duck or Fall in Line
Insurrection at 1600 Pennsylvania Avenue
Many 'Ivory Towers' Have Become Bastions of Indoctrination
Should Sicker Patients Pay More for Health Care?
It's Not Only Black Lives That Matter
The Democrats Might Want to Move to the Right
It Could Be That We Are in For a Long Four Years
Warren Buffet Might Have the Answer to Health Care Reform
You Have to Give up the Kool-aid to Find the Truth
Bashing Trump has been Personal from the Beginning
Gorsuch May Come Back to Bite the Democrats on the Butt
The Mayors Seem to Forget They are Not Rulers of Their Own Fiefdoms
The Republicans Just Couldn't Get Their Act Together
The Alarming Reach by the Federal Courts
Maybe I'm Becoming One of Those Conspiracy Nuts
Maybe It's Time to Let California Go
The Land of Opportunity. But for Whom, and at What Cost?
No More Mr. Nice Guy
The Health Care Debts We Must Prevent
When Social Disobedience Becomes a Habit
Don't Forget the Foundations of Health Care Delivery
The Difficulties in Providing Health Care Coverage to the Uninsured
The Underlying Concerns of Health Care Reformation
How Managed Care Threatens the Doctor/Patient Relationship
As the Feds Cover More, They Pay Doctors Less
How Third Party Payers Took Over
How Liability Concerns Shape Health Care Delivery
'Marketing' is Medicine's Double-Edged Sword
The Changing Role of the Health Care Professional
Is Medical Care a Right or a Privilege?
Clinton's Loss Was Just the Tip of the Iceberg
Maybe the KGB is in on It Too
A Relook at the Draft
Will President Trump Determine Hillary Clinton's Fate?
Our Illegal Immigrants Could Tip the Presidential Election
Stopping this Country's Descent into Mediocracy
Advice from Churchill and Lincoln
Trump's Gettysburg Address Should Serve as the Template
I Might Not Invite Trump Over for Dinner, but I'll Still vote for Him
When the Dust Settles
Economic Globalism May Be Setting Us Up for the Big Fall
Stripping the Presidential Candidates Down to Their Bare Bones
Is Donald Trump Racist?
The Democrats May Need Joe Biden Yet
Colin Kaepernick: A Poor Big Rich Kid?
How the Government Subsidies Will 'Break Our Bank'
It's Impossible That Hillary Doesn't Know
Are Gold Star Families Being Used to Pimp for the Political Parties?
If the Republicans Abolished Slavery, Why Do Most Blacks Vote Democratic?
Are the Police Racial Profiling?
Trying to Understand the Black Perspective
Will Obama Ever Get Beyond His Color?
A Takeover Without a Shot Being Fired
The Main Reason to Vote for Trump is Hillary Clinton
Two Black Men Who Had a Chance to Change the World
How the Opponents of Voter ID are Gaming the System
If Trump Wins It Will Be a Miracle...
Their Chance to Move Up has to Start by K1
If Obamacare Comes Off the Track
Political Correctness is Taking Over
The Real 'Donkey' in the Room That's Not Closing Our Borders
Should Our President 'Tighten His Belt'?
The Drug Epidemic is Symptomatic of Much Bigger Problems
Trump May Be a Visionary, but Is That Enough?
It's Not the Voters, Stupid. It's the Party!
There Will be Others after Bernie Sanders
Are 'Black Lives' Being Taken for a Ride?
Taking a Closer Look at John Kasich
Critiquing Ted Cruz
Who Will End Up Taking the Blame?
Dump Trump? Not So Fast!
I Don't Like Donald Trump, But ---
Maybe It's Time to Lighten Up on George W. Bush
Have the Clintons Permanently Tarnished the White House?
'Chasing the Ponytail'
The Silent Majority Had Better Speak Up
It Should Be about Who Has the Right to Vote
A New 'Centrist' Party--- It Could Happen
How Much Money Does This Country Really Owe?
Truth or Dare: Is Trump's Campaign for Real?
It Happened Without a Shot Being Fired
Is Uncle Sam the Refugees' Bogeyman?
Another Trudeau Takes Over in Canada
Are We Crazy? The Junior Varsity Is for Real
Capping Congressional Shenanigans
When Will the Senate Democrats Stop Cowing to Harry Reid?
The 'Hunger Games' Debate
October 26, 2015 : Why Not Just Tell the Truth?
October 19, 2015: One Election Away from a Possible Constitutional Convention
October 12, 2015: Sanctuary Cities Could Be Our Downfall
October 6, 2015: Is Donald Trump Presidential?
September 30, 2015: Facing the Real Threat of Terrorism
September 14, 2015: Have the Clintons Used Up Their Nine Lives?
September 8, 2015: Because of Trump, the Mongrel Dog Might Catch a Break
September 1, 2015: Is This Just Wag the Dog?
August 27, 2015: Where Are They Going To Get The Money?
August 10, 2015: Pushing for a National Police Force
August 3, 2015: The Only Solution to Illegal Immigration
July 27, 2015: What's So Great About Bernie Sanders?
July 20, 2015: Trying to Save the Middle East from Itself
July 13, 2015: What Difference Does It Make?
July 6, 2015: Maybe We Can Learn from the Lessons of ISIS
June 30, 2015: It's Time to Put the Confederate Flag to Rest
June 15, 2015: The President Has Already Decided on Global Warming for Us
June 8, 2015: This Century's Berlin Wall
June 2, 2015: Groveling for the Truth at the Trough
May 27, 2015: Would Our Forefathers Find Fault with Obama's Vision for America?
May 12, 2015: Do They Remind Us of the Thénardiers?
April 28, 2015: Why Politics and Religion Don't Mix
April 17, 2015: What It Takes to Have a 'Good' Marriage
April 13, 2015: We Live in One Big Infomercial
March 30, 2015: Our 'Kick It Down the Road' Generation
March 10, 2015: What Can President Obama Learn from Neville Chamberlin?
February 25, 2015: Are We Going to Look the Other Way, Again?
February 10, 2015: The Fall of the "American Empire"?
January 8, 2015: Physicians Desperately Need an American Medical Association
December 12, 2014: Doctors for Hire
November 24, 2014: Boondoggle?
November 3, 2014: 'Working for the Man'
October 10, 2014: Should Our "Squatters" Get a Free Ride?
September 10, 2014: The Crisis of Truth in the White House
August 11, 2014: A 'Fox' in the IRS's Henhouse
July 10, 2014: Houston: We Have Had a Problem!
June 10, 2014: The 'Perfect Storm' at the Veterans Administration
May 12, 2014: Border Boondoggle
April 30, 2014: The Reverend Jessie Jackson and Geronimo
April 21, 2014: The Surgeon General--- Where’s the Beef?
April 8, 2014: Complacency, Acceptance Then Dependency--- A Master Plan?
March 10, 2014: Does Bedside Manner Matter Anymore?
February 10, 2014: Outcome Measurements Could Be a Two-Edged Sword
January 10, 2014: It Always Seems to Boil Down to Politics
December 10, 2013: The End of the Shift or the Next Patient
November 11, 2013: Have We Given Up On Meaningful Dialogue?
October 11, 2013: Is This All Just About Obamacare?
September 10, 2013: Even the Lexicographers Have Noticed the Change
August 8, 2013: Where Did Physicians First Go Wrong?
July 10, 2013: It's Only a Matter of Time...
June 10, 2013: Maybe I Should Have Been a Veterinarian?
May 9, 2013: The Intangibles--- Why Paying Paying for Performance Won't Work
April 10, 2013: The Money Has to Come from Somewhere
March 11, 2013: Is Doing the Right Thing Passé?
February 11, 2013: What Would Hippocrates Do?
January 10, 2013: The Physicians' Vanishing Covenant
December 3, 2012: Where Is The Outrage?
November 19, 2012: Why Don't You Get In Line With Me?
October 29, 2012: Obamacare Has 'Thrown Our Seniors Under the Bus'
October 10, 2012: "I Don't Like Spinach"
September 10, 2012: The Widgets in Our Waiting Rooms
August 27, 2012: Once the Dust Settles
August 10, 2012: Same Song, Final Verse?
July 23, 2012: President Obama 1, President Clinton 0
July 10, 2012: Chief Justice Roberts' Decision Might Just Be a Stroke of Genius
June 11, 2012: The 1.5% Penalty
May 10, 2012: Groundhog Day---Our Boring Problems?
April 10, 2012: The Three Little 'Doctors'
March 9, 2012: Looking the Other Way
February 10, 2012: Mumble, Grumble, then Tumble
January 10, 2012: Thinking About Getting Out of Medicare? Think Again
December 12, 2011: Is Walmartcare the Answer?
November 10, 2011: Have Physicians Lost Their 'Shared Vision'?
October 10, 2011: Opt-In Versus Opt-Out: Petty or Important?
September 9, 2011: Whatever Happened to the 'Whole' Story?
August 10, 2011: Maybe This Wasn't George W. Bush's Recession?
July 11, 2011: Shotgun Medicine
June 10, 2011: Medicine's 'Tipping Point': What's Next?
May 10, 2011: Have Physicians Sold Their Souls?
April 11, 2011: Turf Battles, but on Whose Turf?
March 10, 2011: Death Panels: Probably Not------A Trojan Horse: Maybe
February 10, 2011: Individual Mandate: The Deeper Issues
January 10, 2011: What if There Were No AMA?
December 10, 2010: Birthright Citizenship: The Silent Costs
November 11, 2010: The State of the Medical Profession
|
