It is not easy to capture the attention of readers with more bad news about the soaring costs of medical care in the U.S., but a recent article in The New York Times may have succeeded with the simple headline: “The $2.7 Trillion Medical Bill.”
By Paul Hicks
It is not easy to capture the attention of readers with more bad news about the soaring costs of medical care in the U.S., but a recent article in The New York Times may have succeeded with the simple headline: “The $2.7 Trillion Medical Bill.” It focused on the much higher cost of colonoscopies in this country than elsewhere as an example of why ordinary medical services may be even more significant than extraordinary ones in driving up the nation’s trillion-dollar health bill to $2.7 trillion.
A major problem identified in the article is the lack of coordination among the multiple health care providers participating in a colonoscopy and other types of patient care. Let’s say that your internist or primary care physician refers you to a non-affiliated gastroenterologist (GI) who recommends that you have a colonoscopy. The procedure is then performed either at a hospital or at an ambulatory surgical center. Assisting the GI specialist will be an anesthesiologist and at least one nurse.
The cost of compensating all those medical professionals and institutions is high, but it is likely to be even higher when the work they perform and their incentives (if any) to control costs are not coordinated. That is how the potential cost-saving benefits of an Accountable Care Organization (ACO) can make a difference, especially because of the large and growing segment of the population covered by Medicare.
Under the Affordable Care Act (“Obamacare”), medical providers who agree to coordinate services for patients and also meet certain quality standards in an ACO can share in any savings they achieve for Medicare. One of the nation’s pioneer ACOs is the WESTMED Medical Group, a multi-specialty medical practice with offices in White Plains, Rye, Yonkers, New Rochelle, Purchase, and Scarsdale. There is one other Westchester-based ACO that is headquartered in Mount Kisco.
All of the 250 WESTMED doctors participate in its ACO, supported by nearly 1,000 other staff members. Certification as an ACO is a logical progression from the integrated practice model WESTMED has developed since the late 1990s. A key part of their successful growth is a system of electronic medical records that can be accessed by all authorized staff members. In the above colonoscopy example, the internist, GI specialist, anesthesiologist, and nurse would all be able to look at your current and past medical history. That could result in avoiding duplication of tests as well as the time-consuming and costly transmission of paper records between non-affiliated caregivers.
Traditionally, health care providers have focused on their individual responsibilities in caring for patients one at a time and being paid on a fee-for-service basis. Under the new system, the ACO is accountable for its performance in providing high-quality, cost-effective care for a large population of patients.
Another innovation is the use by ACOs of designated care managers to help track and manage the care of patients who have complex medical conditions, providing them with continuing support and identifying problems before they become acute and require hospital admission or readmission.
The goal of increasing patient engagement requires ACOs to provide patients with more and clearer information about test results, diagnoses and procedures. WESTMED has begun emailing slide presentations that describe diagnosed medical conditions and the surgical or other remedies that have been prescribed, which allow patients and their family members to become better informed and more engaged in their own care.
The Center for Medicare and Medicaid Services (CMS) uses historical claims data to determine whether a patient should be included in an ACO’s “defined population” (there are approximately 11,500 Medicare beneficiaries participating in the WESTMED ACO). If the patient’s primary care doctor (or in some cases, a specialist) is part of an ACO, the patient is attributed to that ACO.
From the patient’s perspective, there are no adverse results of being a member of an ACO. The benefit coverage under Medicare and any supplemental insurance policy remains the same, as does the cost to you. Equally important, your right to use any health care provider that accepts Medicare will not change even if that provider is not part of an ACO.
A recent report by the United Hospital Fund concluded: “Creating these new accountable care networks will not be easy or quick, and it will take some time for them to achieve their potential-if, in fact they are able to do so. Meanwhile, the existing methods of organizing, delivering and paying for healthcare services will not disappear overnight.”