Editor’s note: This commentary is by Gerry Silverstein, who lives in South Burlington and has interests in individual, community, and global health.
[A]fter reading recent comments by Al Gobeille, chair of the Green Mountain Care Board (GMCB), I have come to believe he (a) is misinformed, (b) has failed to read the medical literature on accountable care organizations (ACOs), and/or (c) feels it is acceptable to make unsubstantiated statements regarding the success of ACOs in order to justify his support for the all-payer model.
Why do I make such accusatory statements?
In the Aug. 16 issue of the Journal of the American Medical Association (JAMA), two articles are presented that respond to the question: “Has the ACO experiment been successful?”.
Zirui Song and Elliot Fisher, physicians from the Dartmouth Institute for Health Policy and Clinical Practice, say yes but financial savings (if they occur) are extremely small, so much so that the following qualifier is offered: “There is no question, however, that the ACO model has yet to achieve the benefits many advocates hoped for, at least for the Medicare ACO programs.”
Further, Al Gobeille has stated, “ACOs work best with large systems that have been working on integration for a long time,” like the UVM Medical Center. “They work least with small hospitals and independent physicians where they’re used to doing their own thing.”
In contrast, Song and Fisher state: “ACOs led by primary care groups achieved greater savings than those integrated with hospitals” (McWilliams et al, June 16, 2016)
Kevin Schulman and Barak Richman, physicians at the Duke Clinical Research Institute, argue that the ACO experiment has NOT been successful, and offer the following: “Based on 3 published evaluations of the ACO program, the experiment so far has failed to produce needed efficiencies” (see article for supporting documentation).
The authors go on to state: “The ACO model also accelerated a trend of hospitals acquiring physician practices in support of the ACO model, enhancing market power of these hospital-led organizations.”
They continue: “Monopoly hospitals, those that dominate a local market with no other competing hospital, have 15.3% higher prices than hospitals in more competitive markets, and hospital consolidation is responsible for sharp price increases across markets within states. In California, costs of care per patient when seen in a physician practice owned by a multi-hospital system in 2012 was $4776 compared with only $3066 when the practice was physician owned.”
There is nothing in the all-payer program that rewards the individual for accepting responsibility for leading a healthy lifestyle and minimizing their health care needs and demands on the health care system.
Finally in a recent Wall Street Journal article (Aug. 1, 2016: “How I Was Wrong About ObamaCare”), Bob Kocher, the only physician on the National Economic Council chosen to advise the president on health care policy, and who initially supported ACOs being instituted by primary care groups owned by large hospitals, had this to say after reviewing recent developments: “Over the past five years, published research … has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.”
Al Gobeille has consistently argued there is a national consensus that ACOs are the best way to control costs, yet study after study has detailed there is no consensus, and especially not ACOs run by large monopolistic hospitals. Moreover, most studies have detailed little if any benefit in terms of health care improvement.
The chair of the GMCB does a disservice to the citizens of Vermont by making statements that are directly contradicted by authors publishing in the peer-reviewed medical literature.
My own experience with accessing the health care system will serve as an example of the much greater costs associated with physicians employed by large monopolistic hospitals. In 2015, I had a problem with my hand. Since my primary care physician is with the UVM Medical Center, I sought an appointment through their orthopedic department. The earliest appointment required a six-week wait.
Not wanting to wait six weeks I made an appointment with an independent orthopedic group, which I was able to see within two weeks. I saw an orthopedic hand surgeon (MD). That practice billed my Blue Cross Blue Shield insurance $126, and BCBS paid $63.51.
Wanting a second opinion, I kept my appointment with the UVM Medical Center. My appointment was with a physician assistant who billed BCBS $292, of which BCBS paid $228.83.
The UVM Medical Center charged a rate more than 200 percent higher than an independent group for me to see a PA vs. a MD surgeon, and BCBS paid a rate more than 300 percent higher to the UVM Medical Center than to the private orthopedic group.
It will not surprise the reader to learn that the private orthopedic group has recently been bought by … yes, you guessed it … the UVM Medical Center.
Medicare will soon become my primary insurance. Should the all-payer program (which employs ACOs to manage patient care) be adopted and my primary care physician join the program, I will be forced to either (a) become a capitated participant in my physician’s practice (where Medicare pays my provider a monthly fee for my care even if I do not see or network with my physician), or (b) transfer to another physician who continues in a fee for service program (if I can find a physician who is doing this and still accepts new patients).
Although no one is guaranteed a life without serious adverse health conditions, people can lead a healthy lifestyle that maximizes the chance that their health care system needs will be compatible with a financially stable insurance program (such as Medicare which is projected to run a deficit within 15-20 years).
I believe that the real reason behind the Shumlin administration and the GMCB promoting the all-payer program is to set up a system that takes insurance premium payments made by healthy insured individuals (over a lifetime in the case of Medicare), and uses them for the care of individuals who are less healthy.
It is obviously true that some people, in spite of doing everything possible to remain healthy, develop serious and very costly medical conditions. Personally I am (very) happy to have my health insurance premiums contribute to covering the expenses of these individuals.
But for the very large number of Americans who (knowingly) have adopted an “unhealthy” lifestyle (smoking, excessive drinking, self-chosen sedentary lifestyle, willful consumption of an unhealthy diet), I am opposed to having my health insurance premiums (directly as a result of cost transfer via capitation) pay for their care when their ill health is due to lifestyle choices … but that is what the capitated all-payer will force me (and others) to do.
Although the GMCB wants to adopt an all-payer program where ACOs like the UVM Medical Center will be financially rewarded for reducing health care costs (if they occur at all), there is nothing in the all-payer program that rewards the individual for accepting responsibility for leading a healthy lifestyle and minimizing their health care needs and demands on the health care system.
The misinformation regarding ACO performance disseminated by the GMCB (i.e., statements not supported by the peer-reviewed medical literature), as well as the lack of a holistic assessment by the GMCB of the challenges facing our health care system at both individual and societal levels, is tragic. Although we live in a democracy, the all-payer program will increase government control at the expense of individual rights and responsibility. Vermont citizens should voice their opinion on what I believe to be yet another misguided Shumlin administration health care program.
