Getting to Why
Trombley and associates have reported the first year experience of CMS’ experiment with pre-payment of savings to accountable care organizations (ACO) serving rural areas. The study used claims and enrollment data for 41 ACO’s located in rural areas and compared the observed spending for patients receiving care within the assigned ACO to spending for patients not associated with an ACO. What was different about these ACO’s as opposed to those previously studied is that CMS made an advance payment based on projected savings, rather than paying “in arrears.” The logic of this is that rural organizations often lack the capital to make an investment in the management systems presumed necessary to operate an effective ACO. The map shows a cluster in my area of the mid-South and random clusters elsewhere.
Taken as a group, the ACO’s had $28.21 less spending per beneficiary per month, (PBPM) which represented a 2.8% reduction in the mean expected spending of $1,013.56 PBPM. Analysis showed most of the savings in three areas: $7.98 PBPM in hospital spending, $9.18 PBPM in outpatient facility spending, and $6.24 PBPM in skilled nursing facility spending. Several analyses were conducted to insure the robustness of the findings and their statistical significance. The authors note, however, that these are first year results, and it is unknown if the advantages can be sustained in the second year.
I can’t speak for the other areas, but my small local area ACO was based on a long-established multispecialty group and our data showed most of our savings were in the same places reported in this report. But many of the ACO’s in this report were new consortia, with little or no prior experience in “managing care,” so what was seen was simply efforts to keep patients out of the emergency room, probabaly by improving access to urgent care. However, the magnitude of the savings is comparable to that seen by mature managed care organizations with extensive infrastructure.
CMS is likely to conclude pre-payment of expected savings was the incentive needed to make things work. I am less sanguine, because the comparator group of “unmanaged” care is operating with a different set of objectives. Consider the hospital, typically the largest source of capital in a rural ACO. To make the program work, volume in the ED, in-patient wards and the SNF all need to be reduced. This loss of patient-care revenue may, or may not, be offset by the shared savings payment, so for hospitals already concerned about staying in business, (and a number have closed in my region,) this looks like a tough gamble.
The ER physician has a different set of issues. He/she is faced, particularly in rural areas, with a large volume of patients who really need primary care. While CMS will pay for the care provided by the doctor regardless of location, the ER physician is also under the gun to make rapid dispositions—four hours or less being the gold standard. So, there is a not so subtle pressure to be fast and make a quick disposition. But as is well documented, all primary care works best when the physician can take the time needed to make sure the patient really understands the why of the recommendations, not just the what. Admitting the patient, though, solves the ER physician’s dilemma—providing both care and stopping the clock.
The hospitalist has yet another perspective. He/she is paid only for taking care of inpatients, so there is pressure to admit the patient. When compounded by a lack of resources for ready outpatient referral, the default option becomes “admit.” But once the patient is admitted, the pressure is on to get them back out as quickly as possible. Length of stay becomes the metric of choice. Some patients, of course, stubbornly refuse to get well in four days, so the default option becomes transfer to a SNF. The growth in the “post-acute” care market in the past few years has been astronomical. Even CMS is studying it.
Since decisions about admission, discharge, and disposition are still mostly in the hands of clinicians, it is evident that changing physician decision-making is key. But is money really the crux for getting the desired result? John E. Jenrette, MD, Executive Vice-President of Cedars-Sinai Medical Network thinks not.
“How many times can we split the dollar into smaller and smaller pieces and put more and more on the plate until I don’t care what you’re telling me? I can’t pay attention; it’s not worth my time and effort…Physicians like money and financial incentives, yes, but they’re not at the core at all…They maybe have this kind of incremental impact if you can put them in the right direction, but I truly believe that if physicians are compensated appropriately for the work they’re doing, the incentives become the icing on the cake, that top performance, the things that we want to pay attention to, want to try to focus on, and reward physicians for that type of behavior.”
His tenets are: 1) follow the money; 2) produce meaningful data; 3) involve physicians; and 4) ask why? Thus, he would ask questions about our current state such as:
“Why does it cost too much in medicine? What part do we play as physicians in the orders, in how we direct our patients, in how they are treated and what happens…There are ways to move physicians in that direction. When I look at what we do from here, the first thing I’ve learned is that I need to take time to develop relationships with physicians. I need to develop trust. I need to convey the why.”
Unfortunately, what I see is mostly efforts to turn the crank on the machine even faster, regardless of output, creating distrust/disengagement/despair on the part of front-line clinicians (not just doctors,) and making it even harder to deal with the shortage of clinicians in rural areas. At some point we need to admit we can’t sustain the infrastructure without the “people ware.” No computer program or high-tech gizmo can replace bedside care delivered with care, compassion and time. Maybe it is time to stop until we can get an honest answer to “Why?”
11 August 2019
 Trombley MJ, Fout B, Brodsky S, McWilliams JM, Nyweide DJ, Morefield B. Early Effects of an Accountable Care Organization Model for Underserved Areas. N Engl J Med 2019;381(6):543-551. doi:10.1056/NEJMsa1816660.
 Wissoker D, Garrett B. Characteristics, Costs, and Payments for Stays Within a Sequence of Post-acute Care. September 2018. Accessed 11 August 2019 at http://www.medpac.gov/docs/default-source/contractor-reports/sept2018_pac_sequence_of_care_w_cov_contractor_sec.pdf?sfvrsn=0.
 Jenrette JE. Physician Incentives—The Importance of the Why. NEJM Catalyst, 7 August 2019. Accessed that day at https://catalyst.nejm.org/videos/physician-incentives-importance-why/?
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