ACOs Unworkable -- at Least for Some Docs?
ACOs Unworkable -- at Least for Some Docs?
Hello. This is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia. I'm Editor-in-Chief of Medscape Nephrology. I'm beginning to wonder whether we will ever be able to get healthcare right in this country. It has become so expensive and so complex. During the past several weeks, a couple of events and thoughts have occurred that make me wonder about how we are ever going to solve this problem. I was at the dentist a couple of weeks ago, and he told me that he pays $45,000/year for health insurance for him and his family, as well as his son (who is in practice with him) and his family. He pays $45,000/year and is expecting an increase of about 10% over the next year. He is trying to figure out how he can possibly afford to help his employees pay for their health insurance.
I was talking to someone the other day who was telling me that the medical intensive care unit (MICU) at his institution was overflowing with patients. The intensivists were having to take care of patients scattered throughout other intensive care units at this hospital. There were so many critically ill patients in the MICU. I then asked, "How many patients on the medical ICU service are going to benefit from being in the MICU?" He shook his head and expressed what we all know: many patients who are in the medical ICU and surgical ICU are there to die and are not really benefitting from what is very expensive end-of-life terminal care.
I had the opportunity to be involved in some discussions about the proposed rule from the Centers for Medicare & Medicaid Services (CMS) about accountable care organizations (ACO). It is just mind boggling how complex and largely unworkable it is in its current form. The idea may be good in making sure that patients on Medicare have identified primary care physicians who will be coordinating their care, but the complexity of it is enormous. I can't imagine, in its current form, that it is workable. For our patients who have kidney disease, I think there is actually risk for harm, depending on whether or not they are in an ACO because of the various financial incentives. Quality issues may get pushed to the side because of the high cost of caring for patients with chronic kidney disease and end-stage renal disease. We all take care of patients who are uninsured or underinsured, and this continues to be a big problem for us.
From a nephrology standpoint, I've been hearing lots of chatter for several weeks about how so few people are going into nephrology any more. One of the reasons is that nephrologists work very hard and, real or not, there is a perception that reimbursement for nephrology services doesn't keep up with the work demands and the stress of being a nephrologist. Clearly, there is at least a perceived disconnect between the financial rewards of being a nephrologist and the workload compared with other specialties within medicine (ie, those that have no night call, no weekend call, 9-5 type jobs with remuneration that may be substantial higher than most nephrologists get). Finally, I think about primary care, partly as an outcome of discussions about the ACOs and their push to get patients into primary care. More and more, as patients become ill with multisystem disease, specialists need to be involved in the care of these patients. Although there is a need for primary care physicians, particularly in certain areas of the country, the value and contribution of specialists to the overall care of patients and the success of healthcare for these complex patients doesn't get completely recognized.
As many are saying, we need better value for healthcare in the United States. We pay too much; we have to pay less. We have to get more value for the dollar. I'm not sure how we're going to accomplish that. There's going to be some pain along the way, but we need to look at providing higher value care for our patients. We also need to look at how physicians are compensated, and make sure that there is some match between work effort, overall contributions to healthcare of patients, and what physicians get paid, in order to continue to be an attractive profession and, for nephrology, an attractive subspecialty. I am interested in any thoughts or comments you have that you can submit through the Medscape video blog site. Thank you for paying attention. This is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia.
Hello. This is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia. I'm Editor-in-Chief of Medscape Nephrology. I'm beginning to wonder whether we will ever be able to get healthcare right in this country. It has become so expensive and so complex. During the past several weeks, a couple of events and thoughts have occurred that make me wonder about how we are ever going to solve this problem. I was at the dentist a couple of weeks ago, and he told me that he pays $45,000/year for health insurance for him and his family, as well as his son (who is in practice with him) and his family. He pays $45,000/year and is expecting an increase of about 10% over the next year. He is trying to figure out how he can possibly afford to help his employees pay for their health insurance.
I was talking to someone the other day who was telling me that the medical intensive care unit (MICU) at his institution was overflowing with patients. The intensivists were having to take care of patients scattered throughout other intensive care units at this hospital. There were so many critically ill patients in the MICU. I then asked, "How many patients on the medical ICU service are going to benefit from being in the MICU?" He shook his head and expressed what we all know: many patients who are in the medical ICU and surgical ICU are there to die and are not really benefitting from what is very expensive end-of-life terminal care.
I had the opportunity to be involved in some discussions about the proposed rule from the Centers for Medicare & Medicaid Services (CMS) about accountable care organizations (ACO). It is just mind boggling how complex and largely unworkable it is in its current form. The idea may be good in making sure that patients on Medicare have identified primary care physicians who will be coordinating their care, but the complexity of it is enormous. I can't imagine, in its current form, that it is workable. For our patients who have kidney disease, I think there is actually risk for harm, depending on whether or not they are in an ACO because of the various financial incentives. Quality issues may get pushed to the side because of the high cost of caring for patients with chronic kidney disease and end-stage renal disease. We all take care of patients who are uninsured or underinsured, and this continues to be a big problem for us.
From a nephrology standpoint, I've been hearing lots of chatter for several weeks about how so few people are going into nephrology any more. One of the reasons is that nephrologists work very hard and, real or not, there is a perception that reimbursement for nephrology services doesn't keep up with the work demands and the stress of being a nephrologist. Clearly, there is at least a perceived disconnect between the financial rewards of being a nephrologist and the workload compared with other specialties within medicine (ie, those that have no night call, no weekend call, 9-5 type jobs with remuneration that may be substantial higher than most nephrologists get). Finally, I think about primary care, partly as an outcome of discussions about the ACOs and their push to get patients into primary care. More and more, as patients become ill with multisystem disease, specialists need to be involved in the care of these patients. Although there is a need for primary care physicians, particularly in certain areas of the country, the value and contribution of specialists to the overall care of patients and the success of healthcare for these complex patients doesn't get completely recognized.
As many are saying, we need better value for healthcare in the United States. We pay too much; we have to pay less. We have to get more value for the dollar. I'm not sure how we're going to accomplish that. There's going to be some pain along the way, but we need to look at providing higher value care for our patients. We also need to look at how physicians are compensated, and make sure that there is some match between work effort, overall contributions to healthcare of patients, and what physicians get paid, in order to continue to be an attractive profession and, for nephrology, an attractive subspecialty. I am interested in any thoughts or comments you have that you can submit through the Medscape video blog site. Thank you for paying attention. This is Jeffrey Berns from the University of Pennsylvania School of Medicine in Philadelphia.
