“It’s Hard Work, but It’s Good for the Soul”: Accountable Care in the Trenches

So how does it feel to practice in the trenches of an accountable care organization? Honestly, I’m not sure. First I’ll write what I do know: what it feels like to practice in a fee-for-service organization, and what it feels like to practice in a capitated organization.

Fee-for-service tempts one to do too much; capitation tempts one to do too little. The most ethical reimbursement proposal I’ve ever heard was that half of my patients would be fee-for-service and half capitated, and I wouldn’t find out which ones were which until the next year. No one would agree to write or sign that contract, but you can’t ignore its appeal.

Stylistically, I prefer capitation. I like the flexibility to think “outside the exam room” and do the right thing for the patient without having to worry about whether there is a relative value unit (RVU) tied to it. But value-based care is hard. The incentive in fee-for-service medicine is to see 2 healthy patients with sore throats and send the decompensating patient with multiple complex medical and psychosocial problems to the emergency room. The incentive in capitation is to add the complex patient on to the end of the schedule. In fee-for-service care, the metrics you are judged on are visits and RVUs. Nice and concrete—and something you can control. In capitation, the metrics are number of patients cared for and how much their care costs—a lot harder to measure, a lot more responsibility, and a lot less control since in the end it is the patient who takes the medication, gets the test done, sees the consultant, and changes their lifestyle. Or not.

I have never been particularly enamored of practicing in a pure fee-for-service system. Admittedly, I have only practiced in the CPT/RVU version of the fee-for-service system that has existed since the 1990s. An awfully weird version of fee-for-service if you ask me, since it only pays for one thing—me in a room with a patient. Not on the phone, not e-mailing, not video chatting. Not talking to their family, even if it’s in person. Not talking to the hospitalist, or ED doc, or their cardiologist.

Even weirder, it pays me a lot more for doing (procedures and tests) than for talking and thinking. And it refuses to pay many of the nonphysician clinicians I’ve worked with over the years for doing the same work, even if they can do it better than I can for less.

Continuing down the strangeness path, even if the system valued talking and thinking as much as I do, that’s not really what it pays me for. Instead, it pays me for documenting from a Chinese menu of CPT codes (one from column A, two from column B). Do I do 3 History of Present Illness (HPI) elements or 4? Did my Review of Systems contain 9 systems or 10? How many body systems did I examine? Why is it that a 99214 requires only 3 stable chronic diseases to max out my diagnostic/management options when it feels like most patients I see have so many more? Don’t I deserve a bonus for each additional one? And, not to hurt the feelings of whomever created this system, it takes a lot more time and energy to explain to the patient about false positives and the danger of doing an MRI for new-onset back pain than to just fill out the form and order it. Do they have any idea how long it takes to explain to a patient why antibiotics don’t cure viral infections? Yet I receive more medical decision-making points for ordering than not ordering the MRI or antibiotic. Really???

And, weirdest of all, they pay me whether or not I help the patient feel better or live a longer, healthier life. They even pay me for fixing my own complications.

As probably every parent in the world has told every child in the world, you get what you pay for. Nothing I’ve described above is actually paying me for the heart of what I do as a PCP—providing accessible, comprehensive, coordinated and continuous (person-focused care over time) care. Yes, at least for my generation, relationships are built, one-on-one in the exam room with the patient. But relationships require quality time together (ask your spouse), something that is hard to do when you are seeing patients every 15 minutes, and half that time is spent tapping away at a keyboard to meet CPT requirements (not to mention Meaningful Use and Joint Commission and every other regulatory body who wants a piece of my time with the patient).

In theory, it would be easy to construct a fee-for-service system that pays for many of the things I’ve mentioned above. I could be much more accessible if you paid me for email and video chats, plus a little extra to cover the cost of keeping the office open late on weekdays and opening on weekends. I could be much more comprehensive if you paid me to provide all the care the patient needed during a visit, not just what they came in for, and to build and work a registry to provide care between visits. I could be much more coordinated if you paid me (or the nurse or social worker I team with) to check in on patients and to communicate with the specialists and other clinicians my patients are seeing. Changing the reimbursement scheme so that I can focus on seeing only the patients who really need to be seen in person by a doctor, and paying enough for that visit so we can have the time together we need, would go a long way to building those all-important continuous relationships.

And some payers are trying to do this. Hence, new CPT codes from Medicare to report transitional care management (TCM) services for patients, and Blue Cross Blue Shield of Michigan making itself a nice return on investment and simultaneously improving quality of care by creating fee-for-service reimbursements that pay for only a small portion of the activities I mentioned above [4].

So when I say I prefer capitation to fee-for-service, what I’m really saying is I dislike the usual fee-for-service system, but I liked the capitation of the physician-led organization that was committed to value-based care and meeting the needs of the community it served [2]. Not the capitation I experienced in the first year and a half of my career, where there were no adjustments for patient complexity, no balancing quality measures, and no idea how to care manage a patient—a system where certain practices “won” by subtly pushing sick patients to seek care elsewhere.

Which brings me back to: How does it feel to practice in the trenches of an accountable care organization? Or specifically, what does it feel like to practice in an academic medical system 2 years into its transition into becoming an ACO?

In 2011, when ACOs were first appearing, they were compared to unicorns: everyone knows what they look like, but no one has actually seen one. Three years on, that seems a bit unfair. I suspect the current analogy should be that ACOs are like werewolves: they behave like fee-for-service organizations day-to-day, but at some mysterious reconciliation moment in the future, they magically turn into capitated organizations. As best as I can figure out, no full moon is involved.