What is the role of competition within an ACO?

I am reading the last chapter of the book Accountable Care Organizations: Your Guide to Strategy, Design, and Implementation by Marc Bard and Mike Nugent. It is well worth the time and thought to read. It appears to me that if they work, ACOs are more likely to be successful in large urban areas where there are large populations of people and large numbers of hospitals and physician groups. The idea is to scale up "production" by designing efficient and effective care pathways. In an urban setting multiple ACOs can exist and as a result there can be a constructive combination of efficiencies within ACO networks and constructive competition among multiple ACO networks. Hospitals and physician groups can "shop around" and even participate in multiple ACOs within a large urban market.

But it is not apparent to me that this is going to work well in smaller markets that lack enough population base to support multiple ACOs. If there is only one existing local hospital and no large physician groups then it appears that there is only one potential "game in town." The challenge there will be the usual one of trying to align the interests of physicians with the interests of the hospital, given shrinking revenue from government payers. But what about the situation in which there are two or three local hospitals in a city and they have a long history of unhealthy forms of competition including frequent law suits? To create an ACO governance body composed of people with long-standing local institutional loyalties is going to be difficult. I am concerned that Medicare beneficiaries and others in such places may lack adequate care because in the absence of an ACO local institutions will not have adequate financial resources to provide quality care. If long-term competitors cannot get past their issues and competitive interests they may be unable to form an ACO in small to midsize places.

Just as Certificate-of-Need legislation led to accelerated spending for costly medical technologies in the 1970s it will not be surprising if the Patient Protection and Affordable Care Act will lead to many attempts by local hospitals to buy out other local hospitals and local physician practices. Coordination that may not be otherwise possible is possible under unified ownership. But there are still laws on the books that prevent some acquisitions and that make it illegal for the very entities that should be talking about forming ACOs from discussing financial matters because such conversations would be anti-competitive. What it boils down to is, do we believe in competition or do we believe in networks based upon cooperation, coordination and trust. It seems as if we want hospitals to compete with each other while at the same time being partners within ACO structures. How can the people who govern an ACO also fulfill their responsibilities to individual institutions engaged in competition with ACO partners?

One of the things that Bard and Nugent advocate for is tightly coupled systems. Can a system be both tightly coupled and internally competitive? Is it reasonble to insist on what amounts to consolidation of institutions while at the same time forbidding hospitals and others from engaging in behaviors that are illegal because they threaten competition?

Helping Patients See the Light

Thomas Goetz of Wired Magazine spoke recently at TEDMED about the potential to leverage the voluntary compliance of patients by presenting them information that is personal, relevant and actionable. In my opinion, our nation cannot rise up to the challenge of providing quality medical care to all citizens without more effectively engaging patients as their (our) own best primary caregivers. Goetz points our that a sense of self efficacy is more effective in producing compliance behaviors (exercise more, stop smoking, and so forth) than is fear as a source of self motivation. Most people want to be healthy. Most people don't want to die a premature death. Goetz believes that "packaging" information for people is an effective way to gain compliance. I believe it is also a way to help reduce overall costs.

Direct link to YouTube video below

ACO regulation design flaw?

Paul Levy's explantion of a possible design flaw in the proposed rules by which ACOs may be regulated is worth exploration.

http://runningahospital.blogspot.com/2011/04/aco-rules-wheres-beef.html

It seems to me that the underlying problem is that many government policies intended to prevent constraints on competition just don't work well in the new paradigm of accountable collaboration. Is it possible that political realties make it impossible to achieve the needed combined goals of increased access, quality improvement and cost constraints? In light of national and global "graying," the reality is that as medical interventions become more successful people will live longer and costs will rise. It seems to me that there is an "impedance mismatch" between population-based healthcare and patient-centered medical care. On the one hand, when acute medical interventions become necessary we want assembly-line efficiencies. But on the other hand, we want to personalize care for each patient. Continuing discoveries involving DNA and genes can bridge the mismatch by allowing the creation of evidence-based protocols for very small groups of patients and even for specific individuals. But to do this the complexity of personalized diagnoses and treatments will increase dramatically, and with complexity the costs.

Yarnell Beatty Speaking on Accountable Care Organizations

Attorney Yarnell Beatty speaks here regarding what is now known and not known about Accountable Care Organizations, as outlined in the new healthcare policy.

Investigation of quality of care in Las Vegas hospitals

This is from Paul Levy's "Not Running a Hospital" blog. In the video below Brian Greenspun, Publisher and Editor of the Las Vegas Sun speaks about an extensive investigation of the quality of care delivered by hospitals in that section of Nevada by reporters Marshall Allen and Alex Richards and others. The essential message is that transparency and the willingness to face up to errors may actually reduce lawsuits and enables a hospital to learn from its mistakes.

Scientific Management, Systems Thinking and Evidence-based Practice

It is Friday evening. I am studying for a first set of questions in the course I am taking at Georgia Health Sciences University. The material involves an overview of the challenges of healthcare management and healthcare policy in the United States. At the moment I am wondering if evidence-based management (and evidence based clinical practices) are only new labels for the old scientific management. When Frederick Taylor calculated the optimal size of a shovel for a particular purpose was he not collecting evidence to be used in practice? And in a way were not his instructions to "Schmidt" (so as to get him to handle 47 tons of pig iron per day) somewhat analogous to telling instructing a manager or a physician in the one best way to do something, as derived from evidence? Is it a surprise that physicians resist systems by which they are evaluated upon compliance with procedures, especially when there are conflicts between the interests of particular patients and the financial interests of organizations?

http://www3.niu.edu/~td0raf1/labor/Story%20of%20Schmidt.htm

Evidence-based clinical practices are based upon observations of outcomes in large populations of patients. But physicians face their patients one by one. It is the particular patient that a physician is trying to understand so as to diagnosis and treat correctly. Under DRG's (diagnostic related groups), for example, the patient becomes a diagnosis. The correct evidence-based process is based not on the patient as a person but on a diagnosis. Many patients have multiple chronic conditions. If we go to evidence-based practice are we assuming that physicians lack the ability to use his or her systems thinking skills (informed by the evidence of personal experiences) to assess the needs of this patient. Does process ultimately replace cognition? Is the use of professional discretion something to be driven out of clinical processes as is variance in industrial processes?

I value evidence, process, efficiency and economy. But I hope that we are not driving good physicians out of the profession by constraints that may in a way reduce the profession to something of an industrial profession in which obedience is more highly valued than personal insights. Physicians rightly value professional discretion and autonomy. If we come to no longer trust physicians as human beings with advanced knowledge and cognitive skills, can we substitute a trust in evidence-based processes?

Summary of New Health Reform Law

Readers hoping to gain a better understanding of the new health reform law will be interested in this summary made available by The Henry J. Kaiser Family Foundation.

http://www.kff.org/healthreform/upload/8061.pdf