Hamster Medicine

Originally published 10/27/2010 on The Doctor Weighs In


No, I am not blogging on veterinary topics now.  Hamster medicine refers to the current practice of primary care in America.  The term was used today by Elliott Fisher – one of the fathers of the Accountable Care Organization (ACO) movement  – at the big ACO Conference held in LA [10/25-27, 2010].  ACOs, by the way, are the hottest thing in the health care industry to date.  Everyone wants to have one, build one, buy one, consult to one or in some other way be affiliated with one – hopefully for the purpose of making money or growing/preserving your share of the lucrative health care market – and, by the way, perhaps improving care along the way.

But, I digress.  Let’s get back to hamster medicine.  If you are a primary care doc (aka PCP), I don’t need to explain the term–you are living it.  For the rest of you, my dear readers, hamster medicine refers to habit hamsters have of running as fast as they can on the little wheel in their cage.  Economic forces have morphed primary care from a relationship-based, Dr. Welby-style practice to one that is driven by the clock.  Fifteen minutes per visit x 10 hours a day = just enough to pay staff and doc and keep the clinic lights on.  If you need more, well, you can always run faster…and longer…and harder.

From the doctor’s viewpoint, it is like being a worker on an assembly line.  From the patient’s standpoint, it is like being the widget being assembled.  Not satisfying for anyone.  What’s to be done?

The policy wonks and industry leaders at the Conference are hoping ACOs are what’s to be done.  The ACO movement holds out the promise that we will, at last, change the way health care is organized and paid for – reducing the need for physicians to sell more and more pieces of work (e.g., services) to their customers (aka patients).

The problem, that everyone at the Conference acknowledged, is transforming our volume-driven system to one that is patient-centric, quality oriented, and relationship-based is going to be really heavy lifting.  Competitors are going to need to collaborate, things are going to be measured, payment is going to be for value (not volume), and patients will have to be engaged in their own care.

So, what exactly is an ACO?

There are some formal definitions.  Here is one proposed by the NCQA:

“Provider-based organizations that take responsibility for meeting the health needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs.”

What it means to be accountable for care is that your doctor, in the context of a supportive organization, delivers care that improves your individual health, and equally important, improves the health of his/her entire population – defined by all the patients on his/her panel.  Accountable care means your doctor listens to your concerns, examines you to look for clues to the diagnosis, orders only/all appropriate tests to confirm the diagnosis and prescribes effective treatment, when available.

It also means your doctor is thinking about you (and all of his/her patients) even when you are not in the office.  Using tools such as registries of people with chronic illnesses and automated care gap reminders based on evidence-based clinical practice guidelines, health needs are proactively identified and responded to.  Care is provided by teams of people – not just the doctor- and it is so much more than a 15 minute office visit once or twice a year.  There are care managers to help people manage their health, there are health educators to teach folks how to use a glucometer or an asthma inhaler,  and there are skilled people who can deliver care in the home when it is needed.

From a patient’s point of view, accountable care means being given good, clear instructions that are compatible with your level of health literacy.  It also means receiving reminders to get needed preventive screening tests and interventions (e.g. flu shots).  It means being prescribed treatments you can actually afford to get and are willing to take. And it means, the office or clinic is open after work and on weekends when you can keep an appointment without missing work.  It means a lot of things that you probably are not getting today.  And, these are all very good things.

Accountable care means being accountable for the cost of care.  Not rationing—although some will try to paint accountable care as rationing.  Not denying needed care, although some care – that which is unnecessary, redundant, or ineffective, should not be paid for by insurance.  By lowering the cost of care – or at least “bending the cost curve,” we will all benefit.  If prices come down, coverage becomes more affordable and more people will have it.  This concept should be honored – not reviled – in this day and age when politicos on both sides of the equation are trying to “own” the concept of living within our means.

We have been gluttons when it comes to health care, over-consuming, if we were insured, because, well, we could.  It didn’t really cost us very much.  But every MRI for knee pain that you demanded, that didn’t add to the information available via a good history and physical, adds to the overall unaffordability of care.  You may have gotten it for modest co-pay, but someone paid the full freight and it did count when insurance premiums were being calculated.

The Department of Health and Human Services (HHS) has articulated the need to transform from our existing hamsteroid delivery system to one that strives to meet new goals – what is being called “The Triple Aim:”

  • Improve care
  • Improve health
  • Lower costs.

That is to say, improve the patient’s care experience, improve the health of the entire population, and lower the cost of care by being prudent purchasers and sellers of these precious and costly resources.

Many people at the Conference said they felt this is our last best chance to fix the broken health care “system” that leaves more than 50 million people uninsured. Fix it or else…or else, what?  Price controls? Single payer? Or some other thing we that we won’t like nearly as well as accountability?  I think they are right.  We have proven that as a society we aren’t as egalitarian as many other countries, but we don’t have hearts of stone.  We are not going to let people die in the streets.  Or are we?

Patricia Salber MD, MBA is a former Medical Director for General Motors and Blue Shield of California, and is now Principal at ZOLO Health Solutions, a firm that advises organizations developing Accountable Care Organizations.

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