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

I have this strong impression that the organization is trying as hard as possible to transform itself with an absolute commitment to not upsetting the very difficult  to recruit and retain specialists who fill the beds with all those high-paying elective procedures. If encouraging them to provide care in a less expensive setting within the ACO gets them upset, why risk finding out what happens when we ask them to fundamentally change how they spend their day, who they work with, and how they interact with patients?

But from my point of view in the trenches, it seems to me that we can’t really achieve accountable care until my day as a doctor, and the day of every nurse, pharmacist, social worker, administrative assistant, medical assistant, and administrator, feels fundamentally different than it did in a volume-based system. Patients make changes when it takes less energy to make the change than to maintain the status quo. Organizations aren’t any different. Primary care usually goes first in moving toward accountable care because the status quo is so dysfunctional. But primary care is only a fraction of the cost of care in the United States. The status quo for specialists, especially those procedural specialists, is pretty darned good. How many of them will make the leap, and how many will resist?

Society is entitled to some say in what it gets for its money. Meaning we, primary care and specialists alike, need to take responsibility for the societal benefits that the high cost of health care is forcing out: the new teacher not hired, the new business not started.

I don’t like change any more than any other doctor. Nor am I fully convinced that accountable care organizations are the right solution to the problems with fee-for-service medicine. But I do know that as doctors we have spent our careers making some pretty big sacrifices for our patients. Maybe I’m naive, but I do believe that most of us will agree to make massive changes in our day-to-day lives. But only after we’re convinced that those changes are the right thing for our patients and society, and hence the right thing for us.

Of course, I don’t need convincing; it’s the way I’ve always practiced. How many visits I’m going to do that day is not what gets me out of bed in the morning. I don’t want my lifetime RVU total on my gravestone. I went to medical school to help people, not to accumulate widgets of care.

So, where to start? I was talking with one of the younger docs in our practice a few weeks ago, asking how things were going. His response is the best argument I’ve ever heard for justifying transformation in the trenches from volume to value: “It’s hard work, but it’s good for the soul.”

Corresponding author: Stuart M. Pollack, MD, 301 S. Huntington Ave., Jamaica Plain, MA 02130, smpollack@partners.org

Financial disclosures: None.