Monday, February 20, 2012


Goldilocks went to Forest Medical Center to look for healthcare.
First she came upon Managed Care.  She said “This kind of care is too small.”
Managed Care means there is an advantage to providing only the care that must be provided and nothing more.  In the abstract, it makes sense.  Why would you want procedure and tests done that aren’t necessary.  The rub is who decides what is necessary care? Who decides?
Usually Managed Care means an HMO.  The physicians in the HMO are rewarded financially for NOT spending healthcare dollars.   They have a regularly scheduled meeting, get a pat on the back, and hopefully a check.
Another scenario where there is an incentive to do less is Academic Medicine.  Physicians who teach residents and are paid by a university usually do not make more money if they see more patients or do more procedures.  They are paid the same salary regardless of the workload.  Doing more procedures does not net them more money, it just creates more work.
The full extent of “less is more” is seen in residency.  What resident hasn’t stormed down to the Emergency Room to dispute an admission to the hospital?  Discharge planning starts on hospital admission as a matter of survival.  More patients on your service = less sleep for you.

Let’s take an example of a patient with Congestive Heart Failure (CHF).  Severe CHF causes frequent hospitalizations.  Let’s say our patient, Mr. Bear, gets admitted to the hospital for CHF.  He receives the usual care and is discharged 2 days later.  The hospital gets paid based on what is called a DRG (Diagnosis Related Group).  If he stays 2 days or 2 weeks, the hospital gets paid the same.  The hospital has an incentive to get Mr. Bear out of the hospital as quickly as possible.    If the hospital tries to create a financial incentive for the doctor to make this hospital stay shorter, it violates the Stark Law.  The Stark Law is there to protect the patient’s interest.  It is to keep financial interest from interfering with good patient care.  Unfortunately, it can have unintended consequences.

Second she came upon Fee-For-Service.  “This kind of care is too large”, said Goldilocks.
Fee-For-Service refers to getting paid for things you do.  This means the more patients you see, the more procedures you perform, the more you make.  In this scenario, “more is more”.  There is a financial incentive to do more, whether or not the patient needs it.  I’m not saying that doctors will always intentionally do unnecessary procedures just to make a buck.  I am saying that financial incentives can cloud decision-making.  The Stark Law is also intended to protect the patient in this example.  If Dr. BB Wolf orders a test to be done at the B.B.WOLF Diagnostic Center, and Dr. Wolf makes money from tests done at his center, he must inform his patient that he could also have the testing done at the L.R. RIDINGHOOD Diagnostic Center.  If he doesn’t inform him of his options in writing, he violates Stark Law.
Let’s get back to Mr. Bear.  Dr. B.B. Wolf discovers that Mr. Bear has iron-deficiency anemia and a small lung nodule.  The doctor does not have a financial incentive to get Mr. Bear out of the hospital as quickly as possible.  He does have an incentive to address his problems now.  He get consults for Mr. Bear’s iron deficiency and small lung nodule, both things which could happen as an out-patient.  This may give more work to Dr. Wolf and his specialist friends.  With the current system, there is no incentive NOT to do this.  Also, this insures the workup is done so that Dr. Wolf isn’t sued when Mr. Bear doesn’t follow up.

Finally Goldilocks came to Accountable Care.  “This kind of care is just right!”   
Accountable Care is hopefully the solution to the problems with the above care models.  The patients are considered not as a discrete visit to a hospital or office, but rather as a whole person with all medical costs taken into account.  With this model, everyone involved in the care of the patient has a reason to keep them healthy.  The more money spent on the patient, the less the doctor makes.  Does this mean deny care for the patient?  No.  It means care for the patient in a way that keeps them healthier and out of the hospital.  If they are in the hospital, get them out quickly.   More importantly, keep them from being readmitted to the hospital. 
In the example of Mr. Bear, he really doesn’t want to spend his days in the hospital.  He would rather take his grandchildren for a walk in the forest.  With an Accountable Care Organization (ACO), the hospital can create an incentive for the physician to efficiently and safely take care of his CHF and send him home.  Stark Law does not interfere in this case.  The ACO then makes sure that he understands how to manage his CHF so he doesn’t end up right back in the hospital.  A team approach and a Medical Home provide the basis for coordinated care for Mr. Bear.  His iron deficiency and lung nodule are evaluated in a reasonable way as an out-patient, at a lower cost for everyone.  He feels more in control of his health and appreciates less visits to the Emergency Room.
These issues are more complicated than Mr. Bear or Goldilocks will ever know.  There is not one easy solution.  What Accountable Care Organizations hope to achieve is better patient care with less money.  The financial incentives don’t encourage too much or not enough.  The incentive is for just the right amount of healthcare. 
I have just signed with an ACO.  It is a leap of faith, but I have always been an optimist.  I am sure there will be barriers and frustrations.  At least in theory, this type of care will be best for my patients and aligns most closely with the way I practice medicine anyway. 


  1. Does Accountable Care mean that doctors will be reluctant to treat/ accept patients with chronic health problems, or with the elderly, or the indigent? [This is Kara Hagen, by the way.]

    1. So far, the first ACO experience will be Medicare. No one will know which patients are in the ACO and which are not. Only the final overall financials will be revealed to the peeps in charge of the ACO. Indigent patients just pay cash or show up in ERs at the moment. Hopefully that will change in the future. Also, the ACO is meant to look at same patient population as a whole for baseline and then look at costs for same population with coordination of the care with the ACO.

  2. I had a heart attack on dec 25th of last year 2012, they had to put in three stints, the next night a blood clot caused my stints to collapse causing once again another heart attack. They explained to me that i have Congestive Heart Failure with an ejection fraction of 30-35%. I have looked up various sites on the subject, but still have no answer. The doctors don't help me either. Could someone please help me to obtain an answer?