The Emperor’s New Clothes – Now About That Emperor

“Light as a spider’s web,” said the Emperor, as he wrapped the invisible cloak around his naked, royal buttocks.

While the weavers were cutting the invisible cloth and twisting the invisible thread, one after another of the Emperor’s staff commented on the magnificence of the garment. Not one of them chose to admit that he was unable to see the beauty, for fear of being judged inadequate. How then, could the Emperor himself confess that he couldn’t see the robes?

I have written about the weavers and the nature of the cloth, but the real story here is about the Emperor. Only the Emperor could stop the charade.

As physicians, and in particular primary care physicians, we are given the opportunity to seek truth. We are trained to look, listen, and touch so that we might see past the complaints and through the noise to find the true source of a problem. We are tasked with honesty, even if those around us, including at times our patients, are not so encumbered.

Our diagnostic skills do not seem to extend to our perceptions of healthcare systems.

The goal of an ACO is to lower cost by empowering PCPs to collect data and then make informed, cost effective choices to improve care. As I wrote previously, the weavers took control of the ACOs. That was never a surprise.

The startling thing is that PCPs have gone along with the charade, complimenting the weavers for their product. As if PCPs chose to see the   altered ACO as the way they wish it could be, instead of what it has become.

In January 2012, the Center for Medicare and Medicaid Services launched the Pioneer ACO Model. This was to be the banner bearer, the trail blazer, limited to only 32 organizations, chosen from 162 letters of intent from across the country. Those selected to participate were required to already have significant experience in coordinated care. Each was also required to have a minimum of 15,000 aligned Medicare beneficiaries. “Applications were reviewed by a panel of experts from the Department of Health and Human Services as well as from external organizations, with expertise in the areas of provider payment policy, care improvement and coordination, primary care, and care of vulnerable populations,” per the CMS report. 

The 32 networks selected were large, hand picked, stringently screened organizations, chosen specifically because of their high likelihood of success. If this were a pharmaceutical study, one would say that this was biased research, not fit for publication. The CMS wanted to ensure that they could show savings in their Pioneer ACO study, so they only accepted the participants that they thought would lower cost.       It didn’t work out.

The Pioneer ACO was to be a three year agreement, with a two year extension option. Now, in only its second year, 1/3 of the 32 expertly selected participants are dropping out… because they are losing money. Most of the remaining organizations are struggling to break even and are renegotiating their contracts.

Even after stringently selecting the participants for their Pioneer ACO, even after fancy accounting gymnastics, and even after investing hundreds of millions of dollars into the infrastructure, the CMS has to stretch to spin a positive.

The July 16, 2013 CMS press release can only point to 33 million dollars in savings to the Medicare Trust Fund for the 669,000 beneficiaries.

That’s $49 per patient. Total. For all of 2012. But please, pay no attention to the millions of dollars invested in the infrastructure, analysis, and start-up costs. We put that in a separate accounting category. It’s only tax dollars, anyway.

As PCPs, we still have an opportunity to get it right. Some of us even believe that we have a responsibility to get it right. Our Nation is counting on its primary care physicians.

The idea that PCPs can control healthcare cost with data and informed decisions is absolutely correct. PCPs are the best hope for the future of healthcare.

                           We do not have to be manipulated by the weavers                                                            or fall in line with our self-conscious advisors.                                     We have been empowered by our commitment to the truth. 

A large healthcare system with massive overhead, multiple agendas, and a giant pool of specialists in a limited geographic area can rarely reduce utilization. Especially over a long period of time. Usually the most significant savings can only be found outside of the large, vertically integrated system. To put it another way, sometimes a patient is better served by a competing facility. Period.

In order to provide the best possible care to our patients, independent PCPs must form networks. We already understand the core values of an ACO. We are the recognized leaders of cost effective care. PCPs are trained to work with multiple specialists and multiple resources from competing centers. New technology allows PCPs to share data and follow guidelines based upon performance and improved outcomes. We can reward behavior that results in healthier, happier patients. And primary care physicians certainly must be able to share in the savings that their efforts achieve. But to do all of this, PCPs must also control the infrastructure and the overhead. It must be our network.

Primary care physicians must be free and independent to utilize the healthcare resource that provides the best result for a given patient in a given circumstance. And that resource often changes depending upon the patient and the circumstance. Our patients, and our country, depend upon our unbiased decisions.

That’s the magic sauce. Independence, blended with honesty. The Emperor of healthcare, America’s primary care physician, must be independent.

And that primary care physician needs to put his clothes back on.

Guy L Culpepper, MD