ACOs: What if the patient just says No?

There is much buzz about Accountable Care Organizations (ACO). Their birth occurred  as part of the Healthcare Reform Act and everyone is vying to be the first on the block to have a workable design.  The concept is that doctors, hospitals and ancillary services will form partnerships and networks to provide care for Medicare services.   The hope is to contain and lower costs.                                                         According to Jenny Gold of Kaiser Health News:                                                                          ACOs wouldn’t do away with fee for service but would create savings incentives by offering bonuses when providers keep costs down and meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers would get paid more for keeping their patients healthy and out of the hospital. Ideally, the providers would be more focused on prevention and utilizing health coaches to follow up with patients thus keeping them on track.  It surely sounds wonderful.

What is not been addressed is exactly what mechanism is going to be used to engage patients to respond? More education? More phone calls?  More visits?  Is the premise that  if the provider is more involved with patients preventive care they will  then make the life changes necessary for better health outcomes?  Umm….

I am not saying it won’t happen but I find myself thinking of the many different types of patients I used to see in practice.  To simplify, I am going to describe three types of patients.  Let’s say all are told they need to loose weight to prevent diabetes and heart disease.  All have family history and other risk factors.  Advise a meeting with the nutritionist, with follow up in 3-4 weeks. A health coach is assigned to make regular calls to give positive input.  Social media and computer programs are offered.

Patient A agrees,  goes to the  nutrition appointment, talks to the health coach, accesses computer aids and comes to follow up.

Patient B agrees, keeps changing nutrition appointment, doesn’t return health coach’s phone calls and comes to the follow up and vows to go to the nutritionist.

Patient C says no.

I don’t think this is unusual in most practices. So many factors go into making behavior changes.  The dynamics of change involve understanding the patient’s lifestyle beyond healthcare needs. For instance, what is the financial situation?  Do you know if the person has a monthly food budget and/or do they access food banks to supplement?  Many people won’t divulge such information.  Are you aware of any mental health issues that could limit participation in a program?  Are there any cultural difference that would impact success?

It takes time and commitment to develop the relationship that gives a provider insight into a potential for behavior change.  Primary care providers are stretched and stressed these days.  Preventive care visits may offer some further insight.  But who will pick up the slack?

The ACO will need to either employ a  broader team to continually evaluate and understand patients dynamics or change the nature of how visits occur (increase patient to doctor face time).  Both translate into increase costs something that is not reimbursable and will fall on the shoulders (and profits) of the ACO.

So if patients do not stay with the program, will there be consequences?  Certainly for the providers because bonuses will be less.  But what about patients?  Will providers drop patients?  I am already concerned that so many PCP’s are requiring potential patients to fill out medical information forms before accepting them.  Complex patients are having trouble finding a practice.

I’d like to see more patient input into systems design.  I think it would help to make it a success.  Hey, a girl can dream!