Found while preparing a talk for the Internal Medicine department on Accountable Care Organizations
Eventually, effective ACOs will hand-pick specialists to become integrated into their provider networks — clinically, technologically, operationally and financially — and those specialists will participate fully in the care model, says Terry Spoleti, president of Glenridge HealthCare Solutions. Specialists working in communities dominated by ACOs will need to perform well or they will lose access to patients, she says.
“There will certainly be winners and losers as specialists compete for referrals based on cost, quality and service,” Spoleti says. “In ACO and population health organizations, utilization will decline, so a smaller pool of specialists will need to serve a broader population.”
Emphasis added,
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January 17, 2013 at 2:51 pm
Robert C. Bowman, M.D.
Nurse practitioners and physician assistants as specialists are less costly for employers as compared to physicians. They can generate more revenue for employers as specialists, rather than in primary care. This is a major reason why fewer and fewer remain in primary care and in employed family practice – the only real NP and PA contribution to health access where needed.
Of course there is the question as to whether many of these specialty services by NP or PA are needed – such as when patients are referred by primary care to specialty care and see the triage NP or PA – a duplication of service. There is also a question regarding how such workforce is trained or supervised.
Then of course we will need more specialists that have broader training – a direction opposite to current academic design. Rural and urban areas in need of physicians also need general types of specialties. Chen and Phillips in Health Affairs demonstrated failure in redistribution of GME slots to rural locations and to result in primary care.
I don’t think that the designers of health care in the United States are too concerned about Accountable Care – likely because they helped to rewrite it their way almost as soon as it was proposed. They were not happy about Medicare and Medicaid, but within a decade it was rewritten. It took them about 5 years to rewrite managed care. They are even more firmly in control now.
Also the designers keep proposing more innovation (more regulations and higher costs of delivery) and higher quality measures for primary care to get additional revenue. The designers fail to realize that quality cannot exist when patients A) put off care as in 40% and B) do not have accessible workforce. Moves to higher cost and distractions from more volume result in more millions moving to less or no access – a clear violation of quality and cost. Few understand that fee for service might just be efficient and effective in primary care – due to greater volume. But in specialty care it is fee for service that drives US health care costs ever higher.
Most family physicians practice in locations where patient situations result in lower quality measures – having nothing to do with physician or practice. The role of social determinants and patient situations is poorly understood. Family physicians are also more likely to be in situations where increasing investment makes little sense (near retirement, tenuous revenue streams). The designers have little understanding of the health care needs of most Americans and those who are most likely to serve them. The designers are too immersed in their own top concentrations of specialty, hospital, academic, corporate, and institution.