"I have Medicare" or "I have good private insurance, so what do I care about the upcoming changes with Obamacare" Well, think again . . .

Posted by Stephen Weinberg, MD FACC FACP
The Accountable Care Act, better known as Obamacare, has, as part of the program, the imposition of Accountable Care Organizations. These are relatively large organizations comprised of hospitals, physicians and in some instances insurance companies. The goal is to provide a better coordinated healthcare delivery experience for the patient. The end result is to improve the quality of care and reduce costs. I outlined some of the issues in a prior post.
That's the easy part. The more difficult issues involve who's working for who.

First, when your primary care physician joins an ACO, you will likely receive a letter from the parent organization introducing itself and that your physician is part of it. An example is this letter from Partners Healthcare in Boston.
What is important to note is that you need to "opt-out" if you so desire. You will otherwise be part of the ACO if you do nothing!

Second, the type of ACO matters as to how your care may be provided. Briefly, ACO's are being designed with various levels of financial risk. Some will have upside risk, meaning bonuses will be paid for reducing costs and maintaining certain quality standards. The other large type is both upside and downside risk where the organization may lose money if costs are in excess of revenues. These losses will filter down to physicians as well as the hospitals. So how might this affect you? Savings can occur by reducing costs through standardizing hospital purchases of equipment, drugs and disposables; standardizing protocols of care; better sharing of information; and coordination of the various aspects of care. Other cost saving measures consist of reducing readmissions to the hospital, reducing the use of expensive testing and therapies (MRI, CAT scans, cardiac cath, PET scans, surgeries, pacemakers, defibrillators, etc.). These are all laudable goals except if they produce harm to patients. Quality indicators are being designed to determine if care is substandard. Unfortunately, these measures are very imprecise indicators and on an individual basis, they are not very helpful. As a patient, you may be injured as a result of withholding care. The financial incentives may be too great to allow for protection of individual patients. It may be that the quest for cost savings may lead to harm of some individual patients. I believe this highly likely. When I was writing my book on healthcare financing several years ago, I performed a non-scientific survey of many of my patients to see if they would accept somewhat less care if the cost savings benefited the country as a whole. Not one patent was willing to accept any change in care! They all wanted to know that their physician had their welfare as the only issue. I feel the same way and as a physician, I do not want an incentive program to influence my decisions regarding care. The pressure to withhold testing and therapy could be so great that patients may suffer, individually. Putting in place purchasing and protocols makes sense, but incentives that may withhold care are dangerous.

So what are the messages that you need to understand?
You may be in an ACO and do not know it.
Your care may be influenced by the policies of the ACO and you may not know it.

At the very least, it is important to provide full disclosure to all patients regarding the parameters of the ACO they are enrolled in. The government should mandate this. The Partners letter is incomplete and needs further details about the positive and negative incentives of the program. With this information, you can then have a conversation with your physician decide what you want to do. If you do not think the ACO policies are something you can accept, you have the option of opting out and changing your physicians.

The more you know, the better off you are!