“It’s Hard Work, but It’s Good for the Soul”: Accountable Care in the Trenches
What do I mean? I am lucky enough to spend 5/8 of my time practicing and 1/8 of my time leading a primary care innovation site for my employer—think Patient-Centered Medical Home on steroids. We’ve made it clear to everyone on the team that we are a Triple Aim–driven practice, and that our job is to keep people healthy, and by keeping them healthy we keep them out of the emergency department and the hospital. By being proactive, coordinating care, having same-day phone, email, and in-person access, staying open until 7 pm and opening on Saturday, booking on a 20-minute schedule, and by aggressively addressing our patients’ psychosocial issues on top of their medical issues, this hardy band of doctors, physician assistants, nurses, medical assistants, administrative assistants, social workers, pharmacist, nutritionist, and community health worker have spent our 3 years together improving population health, providing a great patient experience, and preventing more than enough unnecessary ED visits and hospital admissions to cover the cost of the team many times over. I look forward to going to work in the morning, and leave at night tired but satisfied.
One of our assumptions in designing the practice was that reimbursements would shift from volume to value. When we interviewed pharmacists and nutritionists, we were very clear that if they didn’t create value and if reimbursement didn’t change, we could not guarantee their jobs beyond 2 years. We were surprised, but also breathed a sigh of relief, when 4 months after we opened the organization signed the accountable care agreements. We wouldn’t be too far ahead of reimbursement reform, and if we just executed our vision we would easily financially justify our existence.
Oops. The organization was still being paid fee-for-service in real time. The monthly budget was still fee-for-service. That reconciliation of actual vs. expected cost of care was a theoretical event somewhere off in the future that no one knew how to divvy up. The cost of the extra team members was a current expense in the budget not matched by any revenue. We spent a lot of time explaining a very large variance.
Furthermore, a key financial metric for the organization is percentage of hospital beds occupied, while the practice is hoping to use percentage decrease in ambulatory-sensitive admissions as a metric of our economic success. It feels like a potential conflict, though thankfully this has never become a concern like the budget variance.
And by the way, 80% of our doctors’ clinical salary is still based on RVUs. And we’ve built a perfect system to minimize the docs’ RVUs. Easy visits are done by phone and email, slightly harder visits by the PAs. Visits to manage patients with 1 or 2 chronic diseases the pharmacist and nurses do. Doctors work at the top of their licenses, seeing patients with 5 to 10 problems who don’t fit into any protocol. But that top of the license still usually codes as a 99214. There are no RVUs for working with the team. So the need to generate RVUs (and the revenue that comes with them) remains a major constraint on the practice’s imagination.
Thankfully, there are many people in the organization who recognize our value beyond the revenue line in our budget. The team allows physicians to carry a much larger panel, so we talk about new patients to the system and downstream revenue to those who still think of us as a fee-for-service organization. For those who still live by the percent occupancy metric, we point out that the hospital is still full, and the medical admissions we tend to prevent wouldn't be nearly as profitable as the elective procedures that fill the beds instead. We take complex patients who are running amok through the system and bring them under control, allowing specialists to concentrate on what they do best. We take patients who can’t be discharged safely from the emergency room and inpatient floors because they lack the functioning primary care relationship needed for follow-up and see them within 3 days. And, to their credit, many people can think beyond this year’s budget, and even beyond the ACO reconciliation next year, to our mission of caring for populations.
And maybe, just maybe, that is why accountable care organizations will succeed. Because the people who run our ACO know our practice cares for a culturally diverse inner-city population where obesity and diabetes are huge problems. And they’ve seen our data that the nutritionist-pharmacist team is significantly lowering A1cs. So despite the budget variance they create, the organization keeps paying their salaries. Maybe because the mission of the organization includes meeting the medical needs of the community we serve. Maybe because those lower A1cs earn us quality bonuses. Maybe because those newly in-control diabetic patients make fewer visits to the ED and have fewer costly complications. I’m not sure it even matters why. What matters is they understand my practice and its population in a way that someone in Washington never will and never can.
Imagine if the practice was independent, and I wanted Medicare to pay my docs for working with the team and for all the phone and email care they provide. I wouldn’t even know where to start and, honestly, there is no chance it would happen. Of course, it hasn’t happened yet in the ACO I’m in. But at least in our ACO I know which human being to talk to, and that human being is also a doctor, and he knows my practice and the patients it serves. Yes, he’s my boss, and yes, he has bosses of his own, but at least we are having a dialogue about the possibility of tying less compensation to RVUs.
I tend to be skeptical. It’s a good internist skill. You don’t really want a doc who says, “I just saw it on Oprah, let’s give it a try.” I remain skeptical that ACOs will succeed. But if they do, it will be because they push the decisions about how to allocate resources much closer to the trenches.
Do I have concerns about the ACO in which I live? Plenty. I’ve already mentioned 3: the fact that we continue to budget like we are a fee-for-service organization, the need to “feed the beast” and keep the hospital full, and the disconnect between the system being paid for value while the doctors continue to be paid for volume. To be fair to the naysayers, most of our revenue still comes from fee-for-service reimbursement, with a small but rising percentage coming from ACO contracts. It’s hard to stand in 2 canoes. We have this huge, expensive FFS infrastructure—hospital beds, MRI machines, cath labs, etc. There is a leap of faith involved in hiring the people (RN care coordinators, nutritionists, pharmacists, social workers, and community health workers) who make up the “infrastructure” of an ACO. What if we don’t bend cost trend and having paid all these salaries also have to pay a penalty after we already decreased our day-to-day fee-for-service revenue? Even in the best case, it’s not like systems learn to provide value-based care overnight. So you are hiring the RN care managers now, but it could be years before you see a big enough drop off in visits to shelve the plans to expand the ED.
And all this involves eventually shifting resources from the ED to primary care, from inpatient to outpatient. No department is going to volunteer to do this. Even no-brainers, such as building systems that increase necessary fee-for-service revenue-generating care (screening mammograms and colonoscopies, for example) can create food fights. The most effective outreach to get patients in for these tests comes from the patient’s primary care team. But it takes time, and time is money. And after primary care spends that money, the revenue accrues to radiology and gastroenterology. How do you deal with that? And if you can’t deal with that, how do you divvy up any future bonus the system gets from splitting savings in total cost of care with the insurers?
