Long John Silver's, ACOs, and a Tale of Woe


Anyone who takes care of patients with heart failure knows that exacerbations are often the consequence of noncompliance rather than progression of underlying cardiomyopathy, new atrial arrhythmia, infection, or some other identifiable medical cause. In a brilliant article published in Medical Care several years ago, Dr. Ruben Amarasingham and colleagues at the University of Texas Southwestern in Dallas modeled nonphysiologic parameters and demonstrated their potency in predicting heart failure readmissions (Medical Care 2010;48:981-8). This paper and our general clinical experience are relevant in the current era, in which Accountable Care Organizations are promulgated as the most responsible way to manage patients within a health system.


Is it reasonable to ask physicians to take responsibility for the health of noncompliant patients who can’t or won’t kick the onion ring habit?

In a recent "special article" in the Archives of Internal Medicine, Dr. Neil Calman, president and CEO of the Institute for Family Health, and colleagues wrote: "Payment reform must support [the] ‘expanded denominators’ method for it to have lasting ramifications. Outreach efforts must target not only those patients somewhat engaged in care but also a broader population of patients—those who have touched the health system and are lost to follow-up. In contrast, the final rule for Medicare ACOs attributes a Medicare beneficiary to a particular ACO solely based on whether the patient received a plurality of primary care services from a physician in that ACO. Our health system reforms should focus on these individuals, and health care providers should be held accountable for—and paid for—helping to improve the care of those patients" (Arch. Intern. Med. 2012;172:584-6).

In other words, if a patient has any contact with a health care system, that system may be fully financially responsible for the care of that patient.

This concept brings me to Long John Silver’s and a patient with severe cardiomyopathy who, despite repeated visits with the dietician, social worker, nurse, and physician, simply could not wean himself from fried onion rings and clams at that famous fast food eatery. I won’t mention the illicit drug use either or our efforts to involve the family. But this I can say: Repeated hospitalizations for heart failure were the norm.

My questions for the day: Are cardiologists and hospitals supposed to cure societal ills? If yes, is this the reason we became health professionals? Or are policy wonks once again ruling the day, informing us about our "fractured" approach to patient care and our lack of attention to transitions between hospital and home? Why, if only we had adopted patient-focused care, we would never admit (let alone readmit) anyone! Now you know why I spend 1 hour a day as a sentinel in front of a fast food joint. I grab a quick ejection fraction on every patron entering the restaurant using a hand-held echo and then decide who can stay and eat. I consider this a tale of woe, but at least I am doing my part.

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