If Obamacare is sruck down...Physician salaries will rise!

'Accountable care' apt to grow even if Obamacare is struck down

The New York Times

CHICAGO — Even as she struggled to manage her diabetes, Fannie Cline's condition sank. It was not uncommon for the 69-year-old retiree to have dizzy spells, some so bad they landed her in an emergency room.

But last May, she began to receive extra attention from Gwlie Lloyd, a registered nurse at Advocate Health Care, which runs a number of Chicago hospitals and clinics. Lloyd often phones to check on Cline. She offers advice on diet and exercise, schedules appointments, orders meals for delivery.

As a result, Cline's health has improved. She is more active, the dizzy spells have subsided and she has not been hospitalized since May. Now she spends her days visiting friends.

"It is nice to have someone call you in between your visits to the doctor's office to see how you are," she said. "If my blood sugar is elevated and I feel off balance, she will ask me what I have been eating lately. She might say, 'Maybe you need more oatmeal or fruit.'"

This extra attention is part of a new trend, called "accountable care," a radical departure from traditional fee-for-service medicine. It's gaining momentum partly because of Obama- care and is likely to keep growing even if the U.S. Supreme Court, after hearing arguments last week, strikes down the health care law in June.

Accountable care organizations, or ACOs, as they are known, are medical providers who band together under one business umbrella. It may include primary care doctors, specialists, social workers, pharmacists and nurses.

The big difference is in how they are paid: Instead of an insurance company or the government reimbursing each provider for each service provided to each patient, the ACO is paid simply to care for a group of patients.

If the organization can reduce the cost of caring for the patients while keeping them healthy, it gets to keep some of the savings — a powerful incentive to do things differently, experts hope.

On the other hand, if the ACO can't keep the patients healthy and costs rise, the providers might well get less money.

The ACO strikes some critics as a worrisome repackaging of the early HMOs. But there is little doubt more Americans will be enrolled in these groups in coming years.

"ACOs are coming, and it will change the way we pay for health care," said Dr. Michael Cryer of the employee benefits consultancy Aon Hewitt. "Providers are doing things in a positive way rather than a reactive way. We are seeing the beginnings of a tsunami."

For the past year, Advocate, one of the nation's first ACOs, has cared for more than 200,000 patients insured by Illinois Blue Cross. So far it has managed to reduce hospital stays and overall costs for patients, said Steve Hamman, a Blue Cross spokesman. It achieves this mainly by hiring people like Lloyd, who's called a care manager, to better coordinate the way patients are treated.
Care managers keep patients out of expensive hospitals by reminding them to take their medications, for instance, and by helping them eat properly and by troubleshooting the logistical problems that the elderly and sick often encounter.

"A care manager may care for up to 150 patients, and the savings from keeping these patients healthy, and potentially out of the hospital, pays for their salary several times over," said Dr. Lee Sacks, chief medical officer at Advocate. "But it's more than just the economics. It's the right thing to do."

The trend may have the biggest effect on Medicare. Starting this month, ACOs will begin accepting some Medicare patients. By year's end, the government estimates, 2 million will be enrolled.

Still, some experts worry about the rise of an untested model of care, which is expensive and complicated to put in place. The ACO, they argue, seems similar to the much-criticized practices of HMOs 20 years ago, when doctors were paid fixed monthly fees in hopes they could provide all the care a patient needed. Politicians and news media feasted on horrific stories of patients denied care by their HMOs. And many doctors' practices went bankrupt or out of business.

The ACO structure places even more of the financial risk on providers, said Dr. Joseph Golbus, president of NorthShore University HealthSystem in Chicago.

Although many hospitals nationwide are snapping up local practices in hope of transforming themselves into ACOs, others are hesitating because of the financial risk and fear of more bureaucracy.