In an accountable-care organization, doctors and hospitals share a financial incentive to control costs and improve quality by coordinating care for a defined patient group.
Today, most medical care in Dallas and across the nation is delivered piecemeal. Doctors are paid for each patient visit. Hospitals are paid for each procedure. This “fee-for-service” model rewards caregivers for how much they do rather than how well they do it.
Health economists say it does too little to ensure that the people treating a patient know what’s been done by other caregivers. Too often, the result is duplication, waste and mistakes that are both expensive and dangerous to a patient’s health.
But what sounds like a commonsense approach is full of complications. Accountable care relies on a single, bundled payment that’s spread across all caregivers dealing with a patient. In its model, Baylor, with a powerful hold on much of the North Texas hospital industry, will decide how patients should be treated and how the payment pie is sliced. Doctors, hospitals and insurers in North Texas have a hard time trusting each other. And medical professionals don’t like being told how to do their jobs.
Patients may not like it either. The last overhaul of patient care and payments on this scale took place in the 1990s, when HMOs, or health maintenance organizations, were introduced on a wide scale. Patients rebelled against insurers getting between them and their doctors on decisions about care, and they may not see much difference if it’s a hospital rather than an insurance company making the calls under accountable-care.
In 2000, 3 million Texans were enrolled in HMOs. Last year, it was 852,000.
In that decade, however, Dallas changed from an average spender for health care to one of the biggest spenders in America on a per-patient basis.
Congressional Democrats have struggled for months to write legislation that will extend coverage to more Americans, including many in Dallas who lack health insurance. Insurance might persuade some of those people to seek preventive treatments they now skip because of cost. The legislation also encourages communities to try models such as accountable-care organizations, under the theory that doing so will lead to better care at lower cost.
“I don’t think we can really afford to wait for what might happen with national health care legislation,” said health economist Mark McClellan, keynote speaker for Monday’s summit.
“It’s very clear we need to move to more preventive care, and more coordinated care. While legislation can help address that, there are certainly a lot of steps that can be taken in the meanwhile, ahead of health care reform.”
Roberts said Baylor will not wait for Congress to pass a health care overhaul bill. Instead, he has been going directly to large North Texas employers with a pitch that Baylor can improve quality while lowering costs with an accountable-care model.
“I might go to a Texas Instruments and say, ‘I know you’ve been struggling with your health care costs. Can we help you bend the cost curve?’ ” Roberts said.
Early next year, Baylor will meet with the Texas Employees Retirement System and Blue Cross Blue Shield of Texas to see if it can help slow the growth of the system’s health care costs.
Those costs for the 528,000 participants are projected to be $2.1 billion by year’s end, according to the system’s records.
“We will be looking at a number of innovations in plan design and reimbursement structure, including patient-centered medical homes, clinical integration and an accountable-care organization structure,” Roberts said.
In Baylor’s accountable-care plan, Baylor would be held responsible for organizing its hospitals and physicians to lower costs. In a contract, the employer would have to agree to a number of terms, possibly changing health insurance plans, which could set up fights between Baylor and health insurers. The contract might also require the employer to hire an outside wellness program developer to get workers in shape, Roberts said.
What’s less clear, and more controversial, is whether employers would instruct workers to visit only Baylor doctors and hospitals.
Roberts said he’s unsure what employers will do. If employees are given the freedom to choose their doctors and decide not to participate in Baylor’s accountable-care system, then Baylor has limited power in controlling costs.
If workers are limited to Baylor services, the hospital system secures a steady revenue stream and leverage over regional hospital competitors.
One difficulty facing health providers that are considering accountable-care models is how to sell the idea to patients without their feeling it’s just another cost-control measure.
“The challenge with evidence-based treatment is that sometimes we don’t like what the evidence shows,” said Eduardo Sanchez, chief medical officer of Blue Cross Blue Shield of Texas. Sanchez pointed to the uproar over a federal advisory panel’s recommendations that women younger than 50 don’t need routine annual mammograms screening for breast cancer. The panel warned that early testing causes many more false diagnoses and needless procedures than life-saving cancer detections.
“Does preventive medicine have to save money to be worthwhile?” Sanchez asked. “The response has been that, clearly, it shouldn’t be driven by the idea of saving money.”