How Accountable Care Can Liberate and Empower Physicians
January 24, 2016
Among physicians, there is a lot of anger and fear about the current acceleration toward accountable care. There is a lot of anxiety about what might go wrong. By comparison, there is limited awareness of what can go right, not just for aggregate measures of quality and cost but for the day-to-day work lives of physicians.
At its core, accountable care is a business contract, one that ties pay to performance. This is hardly a radical idea. The complications lie in the details. How is performance defined? What are the measures of cost and quality? For which patients? For which services? Over what time period? Because there are many ways to answer these questions, accountable care contracts come in a dizzying array of flavors.
In this complexity lies much of the anxiety. Here’s the critical point: Tying pay more tightly to outcomes means tying pay less tightly to inputs. And how much do you really enjoy having your pay tied to tasks?
Think about what fee-for-service implies: Distant administrators tell you what you can do and what you can’t, what you will be paid for and what you won’t, tell you exactly how much you will be paid for this job and for that job, tell you how much time you can spend with each patient, how productive you need to be, and precisely how to code every breath you take. (That physicians somehow manage to put up with such treatment, day in and day out, is a testament to the willpower of the profession.)
Accountable care promises something different. For starters, it treats physicians like fully grown adults. It does not tell you how to do your work. It simply sets a target for what you produce.
To appreciate what this can mean, take a moment to think about a patient population that you care about deeply. It could be patients with a particular disease, or perhaps a certain demographic.
Now, give yourself permission to rethink, from scratch, what you do at work each day, and without any reference to ICD codes. Liberating, isn’t it?
Next, give yourself permission to pick your team. What skills do you need? What does each team member do at work each day? It’s up to you. In fact, go ahead and reimagine the entire care model from scratch.
A question: If you had that level of autonomy, and that span of control, do you believe that you could deliver better outcomes at lower costs? Keep in mind that the benchmark for your assessment will be the system’s current performance, which you more than likely agree leaves plenty of room for improvement.
Before you offer your final answer, consider how the destruction of fee-for-service medicine would open the door for innovation in health care delivery. It would remove a suffocating constraint. Specifically, under fee-for-service medicine, you get paid zero for any new, creative and innovative service that you can come up with to keep patients healthier and reduce costs. Even if you deliver jaw-dropping results, you don’t receive one penny until your newly created services are formally blessed by distant fee-for-service administrators.
For example, perhaps you think you could do better for certain patients by shifting your effort upstream, and, by doing so, keep patients healthier and minimize downstream care and costs. Maybe you think that the frail elders under your care would benefit enormously from an occasional MD home visit that included a lengthy care planning discussion and a careful conversation about goals of care. Thanks to the rigidity of the fee-for-service system, you cannot do this today, even though it would quite likely be a good move for both the patients and for the system.
There emerges a core promise of accountable care: It can unleash innovation.
But many physicians just do not see it this way. They are angry. For many, the mere mention of any kind of pay-for-performance contract feels instinctively like an insult. This is not hard to understand. Some administrator who wants to measure performance must believe that physicians are not really doing the best job they can, right? They must feel deep cynicism toward the medical profession, even as physicians work extremely hard to do the very best for their patients, and often at great personal sacrifice. Right?
Not so fast. What if those in favor of pay-for-performance believe that physicians are doing the best they can under the constraints imposed by fee-for-service medicine? What if the intent is to liberate physicians to deliver better care than they ever have?
Beyond anger, many physicians fear accountable care. They are concerned that any metric, no matter how well intended, is flawed. In particular, they worry that they will be penalized financially — implicitly, that they will be blamed — when patients deteriorate through no fault of their own.
Examples of such patients live large in some physicians’ minds. These patients pay no attention to diet. They never exercise. They refuse to stay on crucial medications. That their health worsens should surprise no one. That many such deteriorations are beyond physicians’ control is obvious.
But pay-for-performance does not blame physicians for the condition of individual patients. It measures averages for a population. Yes, physicians will lose on individuals some of the time, but what is their batting average? In aggregate, can they move the ball in the right direction toward better outcomes and lower costs?
Liberated from the insults and infantilizing nature of fee-for-service medicine, most physicians could.