Jeremy Scarlett, MD, a pain management physician with Advanced Pain Management in Milwaukee, Wis., discusses the pros and cons of pain management in Accountable Care Organizations. While accountable care organizations could include several different models, their purpose is to coordinate all aspects of patient care for increased quality and decreased cost. Depending on the structure of the ACO, the organization could disrupt the physician's practice and relationship with patients.
"Overall, quality, cost-effective care is an ideal goal, but I believe it is best left to the physician and peers as well as patients and family to sort through those issues as opposed to the introduction of perverse incentives or external mandates," he says.
1. ACO participation may soon become mandatory. Dr. Scarlett says he predicts that the voluntary aspect of ACOs will eventually disappear following the changes in store for healthcare reform. "The concept of an ACO sounds noble to politicians and administrators — ACOs serve as a way to reign in healthcare costs by having groups of individual providers voluntarily come together to ensure quality care and avoid unnecessary medical services to Medicare patients," he says. "It also appears there will be some type of financial incentive for groups to share in the savings from the actions of the organization. With the sweeping changes to healthcare that are moving forward, I suspect the voluntary participation in these organizations will likely soon become mandatory."
2. Physicians currently practice based on ethical — not financial — incentives. Dr. Scarlett emphasizes that patients are treated based on ethical rather than financial concerns in the current practice environment. "As a physician practicing in our current age of austerity, I feel it is my ethical responsibility to work with other providers in a cost-effective manner to provide quality care to my patients," he says. "I often discuss with patients the costs associated with different tests, labs and procedures because it may influence their level of compliance. I don't practice in this manner because I'm financially incentivized; I do this because it's the right thing to do."
3. Financial incentives in ACOs may negatively affect the physician-patient relationship. Through CMS' Shared Savings Program, ACOs are rewarded for lowering healthcare costs, which can be accomplished by ordering fewer unnecessary tests for patients. However, Dr. Scarlett says, this incentive to order fewer tests may weaken the patient's trust in the physician's judgment and objectivity. "Physicians are required to disclose if they have financial incentives to refer a patient to a particular healthcare, physical therapy or imaging facility," he says. "If that is the case, shouldn't we also disclose if we are financially incentivized by CMS through an ACO not to order tests? How would that be perceived by patients, and how would that affect the doctor-patient relationship?"
4. It is unclear how the terms "quality" and "unnecessary" will be defined. The issue of necessary versus unnecessary testing continues to plague pain management physicians, and these difficulties will likely continue in an ACO. "As an anesthesiologist who subspecializes in pain management, I have come under attack by insurance providers for 'unnecessary' medications or procedures, when these same modalities allow my patients to hold a job and enjoy a quality life," says Dr. Scarlett. In ACO participation, treatment deemed "unnecessary" may be unavailable for patients, even if it could offer value to the patient's quality of life.
5. Physician peer groups should have greater influence in defining key terms that govern ACOs. Many of the current ACO models are governed by non-medical professionals, which collides with physicians' professional experience and expertise. "I believe any judgment on quality or necessity should come from a peer group within the same specialty or subspecialty as the provider being monitored," says Dr. Scarlett, adding that most physicians would not feel comfortable making any type of quality assessments on areas outside their expertise. "A peer group should have some direct discussion with the patient, as the patient is most affected by these decisions."
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"Overall, quality, cost-effective care is an ideal goal, but I believe it is best left to the physician and peers as well as patients and family to sort through those issues as opposed to the introduction of perverse incentives or external mandates," he says.1. ACO participation may soon become mandatory. Dr. Scarlett says he predicts that the voluntary aspect of ACOs will eventually disappear following the changes in store for healthcare reform. "The concept of an ACO sounds noble to politicians and administrators — ACOs serve as a way to reign in healthcare costs by having groups of individual providers voluntarily come together to ensure quality care and avoid unnecessary medical services to Medicare patients," he says. "It also appears there will be some type of financial incentive for groups to share in the savings from the actions of the organization. With the sweeping changes to healthcare that are moving forward, I suspect the voluntary participation in these organizations will likely soon become mandatory."
2. Physicians currently practice based on ethical — not financial — incentives. Dr. Scarlett emphasizes that patients are treated based on ethical rather than financial concerns in the current practice environment. "As a physician practicing in our current age of austerity, I feel it is my ethical responsibility to work with other providers in a cost-effective manner to provide quality care to my patients," he says. "I often discuss with patients the costs associated with different tests, labs and procedures because it may influence their level of compliance. I don't practice in this manner because I'm financially incentivized; I do this because it's the right thing to do."
3. Financial incentives in ACOs may negatively affect the physician-patient relationship. Through CMS' Shared Savings Program, ACOs are rewarded for lowering healthcare costs, which can be accomplished by ordering fewer unnecessary tests for patients. However, Dr. Scarlett says, this incentive to order fewer tests may weaken the patient's trust in the physician's judgment and objectivity. "Physicians are required to disclose if they have financial incentives to refer a patient to a particular healthcare, physical therapy or imaging facility," he says. "If that is the case, shouldn't we also disclose if we are financially incentivized by CMS through an ACO not to order tests? How would that be perceived by patients, and how would that affect the doctor-patient relationship?"
4. It is unclear how the terms "quality" and "unnecessary" will be defined. The issue of necessary versus unnecessary testing continues to plague pain management physicians, and these difficulties will likely continue in an ACO. "As an anesthesiologist who subspecializes in pain management, I have come under attack by insurance providers for 'unnecessary' medications or procedures, when these same modalities allow my patients to hold a job and enjoy a quality life," says Dr. Scarlett. In ACO participation, treatment deemed "unnecessary" may be unavailable for patients, even if it could offer value to the patient's quality of life.
5. Physician peer groups should have greater influence in defining key terms that govern ACOs. Many of the current ACO models are governed by non-medical professionals, which collides with physicians' professional experience and expertise. "I believe any judgment on quality or necessity should come from a peer group within the same specialty or subspecialty as the provider being monitored," says Dr. Scarlett, adding that most physicians would not feel comfortable making any type of quality assessments on areas outside their expertise. "A peer group should have some direct discussion with the patient, as the patient is most affected by these decisions."
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