The Failure of "The Coming Failure of Accountable Care"

An alternative to ACOs?

Anyone remotely interested in Accountable Care Organizations (ACOs), should be aware of this Wall Street Journal article by economist-savant Clayton Christensen on The Coming Failure of  'Accountable Care.' 

Dr. Christensen argues that just because they're in ACOs, a) physicians aren't going to change their money-spending ways, b) without any corresponding "skin in the game," patients will continue to demand high-end services  and c) the rosiest savings assumptions will still be minuscule compared to the total federal health budget.

If true transformation is needed, argues Dr. Christensen, health policymakers should embrace alternative care venues ("Minute Clinics"), downjobbing (let generalists provide specialty care services), non-physician providers (nurse practitioners) and telehealth.

The Disease Management Care Blog thinks Dr. Christensen has it mostly right about ACOs but has less confidence in his alternative solutions.

Minute Clinics: in classic health insurance 101, alternative care settings are not substitutive, they're additive.  Classic economic supply and demand does not apply because most health care services create their own demand.

Downjobbing: in any health care system, the economics are push and pull: costs are avoided, while revenue is pursued.  While the luster of a rich procedure code is enough to drive patients toward specialists, another factor in patient referral patterns is the associated cost.  To put it bluntly, the ultimate value of primary care physicians is the savings that they achieve for patients who represent a cost.

Non-physicians: there are arguments on both sides, but health care ultimately remains a labor-intense environment.  The main argument unaddressed by Dr. Christensen is that playing concertos, flying fighter jets and getting diagnoses and treatment right more than 99% of the time requires 10,000 hours' worth of expertise.

Telehealth: the same Minute Clinic logic applies: typical telehealth could end up being additive, not substitutive.

The Rise of the Non-Physician Expert and Implications for Care Management

The Disease Management Care Blog remembers when one of its patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin's benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there's the Feb. 11 Wall Street Journal, where "Notable and Quotable" refers to the "BA Bubble." Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as "apprentices" and "journeymen" before becoming "craftsmen."

All of which makes the DMCB wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, "alternative" web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.
 
Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. The DMCB's traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

The DMCB also remains impressed by the ready availability of medical information in the public domain that is enabling some laypersons to become astonishingly expert.  In addition to the patient above, think about the self-taught parent of a child with a rare condition or the plucky cancer patient who guides the oncologist toward choosing the right life-saving therapy.  Imagine what happens when IBM's Watson is fully commercialized and available to anyone at anytime.

The physician DMCB understands all the perspectives above, but given the decline of the BA and the law degree, it worries that the medical traditionalists may ultimately end up being on the wrong side of history.

While regulators and the markets sort all this out, this may open another business proposition for care management. As patients with chronic conditions continue to seek ways to better share in their self care, they'll also be seeking providers that best suit their needs and expectations.  In other words, the population health vendors can not only help with shared decision making, but provider selection making. 

More on this in a future post.

Image from Wikipedia