This post is a critique of the New England Journal of Medicine article, “A Model Health Care Delivery System for Medicaid,” by Richard E. Rieselbach, MD and Arthur L. Kellerman, MD, MPH. (http://www.nejm.org/doi/full/10.1056/NEJMp1104873). I will highlight what I perceive to be the potential negative and positive outcomes for our healthcare system, which this article espouses. Text from the article will be placed in italics and my commentary in regular type.
The title of the article, A model health care delivery system for Medicaid, means, I think, that the article describes a design or structure of a place or setting to which Medicaid patients could go, when they are sick. The authors propose a novel care delivery model: Community Health Center and Academic Medical Partnerships, or CHAMPs. They propose CHAMPs as a solution for the expansion of the Medicaid population, which will occur as the Patient Protection and Affordable Care Act (ACA), also known as ObamaCare, becomes fully implemented. Their reasoning is that many of the newly insured (expanded Medicaid population) will seek care from community health centers (CHCs), and, at precisely the time when we need CHCs more than ever, many cash-strapped states are contemplating deep Medicaid cuts that could threaten their survival. These contemplated, state-engineered Medicaid cuts, in my view, support the concept of completely removing state government’s participation in health care and creating one CENTRAL PAYER for our healthcare system. What a decrease of the healthcare dollar burden for individual people living in America that could result in: Fifty less sets of politicians, state legislatures, and all the healthcare business – political machinations that emanate from them. Another joyful thought, that could work for Medicare patients and the privately insured as well. But alas, that is extraneous to the subject at hand, except to note that President Obama and his democratic minions, who aspire to the mantle of Socialism, couldn’t even produce a public option in their glorious ObamaCare. They just had to leave the health insurance companies in place and pretty much unscathed in their dollar-driven, business-profit game, which raises, via the purported cost-shift mechanism, the cost of health care for the people, who actually purchase health insurance on their own or via employer, in order to cover the underpayment of public programs to hospitals and doctors. Some believe the cost-shift is exaggerated. What I know is that my premium and deductible payments increase every year. Back to the article.
CHAMPs are partnerships, which combine the subspecialist expertise, medical technology, and inpatient care of local academic medical centers (AMCs) with the primary care expertise of Community Health Centers (CHCs). The letters, CH, account for community health center; AM, for academic medical center; and P, for partnership. The idea is to sustain CHCs and thereby preserve access to care for Medicaid beneficiaries and other low income patients while gaining control over growth in costs. Laudable concepts these, but, in my view, they continue the discrimination inherent in our healthcare system. Why do we continue with the words, Medicaid, low income, indigent, poor, public, private, Medicare, elderly, SCHIP, etc. to describe groups of patients? How about just sick people, who need to go see their doctor. The authors, of course, are trying to work within the system that is and, I presume, trying to improve it. My view is that the entire ethos of our healthcare system needs to change. It needs to be about the non-conflicted practice of medicine; not about political-business designations; and not about controlling the costs for any payer but rather lessening the cost for individual people living in America. It should be evident that cost savings are not passed on to patients, or should I say “not passed on to consumers” so that I have the correct political-business-economic lingo for referring to sick people.
The authors view CHAMPs as utilizing an emerging subgroup of CHCs known as teaching health centers (THCs) to create a distinctive form of accountable care organization (ACO). These CHAMP ACOs could deliver high-quality, cost-effective care to low-income Americans while training the next generation of health care professionals. Well, now we really have gone “beyond the pale” with all of these new healthcare designations and obfuscations. Accountable care organizations (ACOs), which I have discussed previously (http://www.equalhealthcare.org/2011/accountable-care-organizations-acos/), are structured to interfere with the independent, non-conflicted functioning of the doctorpatient relationship. This is wrong no matter what rhetoric is used to disguise or to justify the interference. The words, high-quality, cost-effective care are little more than a sound bite. High quality care comes from sound, ongoing, non-conflicted doctorpatient relationships, which I do not believe can exist in an ACO. Organizations, which offer financial incentives to doctors, by definition conflict the doctorpatient relationship with the dollar bill. Cost-effectiveness is another persuasive term, which has been assimilated into our medical lexicon but for which the clinical utility is hard to understand. (http://www.acponline.org/clinical_information/journals_publications/ecp/sepoct00/primer.htm) But gosh, it sure sounds good, when one says, “high-quality, cost-effective care.” Back to the article.
The authors go on to talk about CHAMP-affiliated THCs. So, we have Community Health Center and Academic Medical Partnership-affiliated Teaching Health Centers, which would somehow be, or be wrapped into, an ACO, accountable care organization, with the designation CHAMP ACO. I’m still waiting for the part which says the doctor sees a patient and that together they form a mutual trust, which is a sound, ongoing, non-conflicted doctorpatient relationship.
CHAMP-affiliated THCs would offer enrollees ready access to high-quality primary care in a network of patient-centered medical homes supported by electronic medical records and other modern care innovations. The AMC (academic medical center) partner would provide back-up specialist care, as well as access to imaging, laboratory tests, and inpatient care. It is interesting that the specialist is referred to as a “back-up”, when so many cases are beyond the educational-clinical reach of the primary care doctor. Indeed, in my view, when the case reaches that point, the specialist is the one, who should be guiding the management of the case. He/she should take it over and provide not only the specialty input but also the primary care input. That seems to me to undo the imposed fragmentation of health care, which articles like this one espouse.
The authors continue to discuss their CHAMP-affiliated THCs. THCs would take a more robust approach to primary care than is typically found in AMCs, which tend to emphasize subspecialist practice. Medicaid patients would probably prefer an ACO that offered primary care close to their homes, rather than being forced to travel to hospital-based clinics. Ah yes, the travails of 21st century travel from your home in the hinterlands all the way to the academic medical center. I can see it now: 21st century suburban outposts, which funnel a few dollar-triaged medical cases forward to the ultimate bastion of medical care, the academic medical center. The fundamental basis for this dollar triage is, of course, the nebulous cost-effectiveness measure, undoubtedly applied by cost-effectiveness experts. I suggest that these outposts will actually increase the fragmentation of care by creating a literal and figurative distance between the primary care doctor and the specialist, in the model described.
Because CHAMPs would be built on a backbone of primary care, they should be able to operate less expensively than an organization built around hospital-based specialist care. Sure they can, because the creation of primary care holding pens is much less expensive than thorough medical evaluations by an experienced, knowledgable specialist. Herd those cattle into the holding pen and don’t let them out until the slaughterhouse is ready for them. The authors espouse the practice of the dollar bill not the practice of medicine. The way to control costs is to definitively control the price paid for services and product across the entire country. Having the dollar bill (or lack thereof) function as an impediment to thorough, advanced medical evaluation and treatment is GARBAGE. It conflicts the clinical decision making within the doctorpatient relationship. It’s wrong a thousand times over.
To encourage efficiency, CHAMPs should accept global capitation, with proper adjustment for case mix. This payment approach would give CHAMPs a powerful incentive to devise and refine their strategies for achieving high-value care by reducing waste and needless duplication of services. Just what is high-value care? How is it determined that services were needlessly duplicated in any patient’s case? Is it done by a cost-effectiveness expert, who reviews a patient’s chart a couple of months later but who has no idea of the doctor’s thinking or the communication between the doctor and patient during the office visit or hospitalization?
To doctors I say, “Do not join an ACO, a CHAMP ACO, or any other organization, which burdens you with financial incentives or any other kind of pressure, which could conflict your clinical decision-making.” When these organizations become your employer, they own you, because they pay your salary. The patient should be a doctor’s sole employer. Then via a beautiful mutual trust, called the doctorpatient relationship, sound, ongoing, non-conflicted medical practice can occur.
R. Garth Kirkwood, MD