The New England Journal of Medicine has a very good series on the implementation of the ACA (Affordable Care Act) or imminent arrival of socialism as ushered in by PPACA (Affordable Care Act) depending on your politics. In the article this week, John Kastor details the potential impact (or lack thereof) of Accountable Care Organizations (ACO) on the Academic Health Center (AHC). As a physician who has spent almost his entire career in academics, I have seen how change happens (slowly) and how difficult the transition is for some. As the new law is being implemented despite some controversy, it is important that we in academics prepare for the changes as best we can.
Dr Kastor points out that the concept of the ACO is completely contrary to the way medicine is practiced in the AHC. AHCs tend to be rather top heavy with sub-sub specialists. In contrast
The ACO concept is predicated on the primacy of primary care, with doctors, nurse practitioners, nurses, and other health care providers working together to supply the most efficient, successful, and economical care for their patients.
He also points out that the AHC administrative structure may not be conducive to an ACO infrastructure. The tradition is for colleges of medicine to be a part of a larger university. The university is typically composed of many colleges, each of which is headed by a Dean. While this works for arts and sciences, it can be problematic if the college is expected to generate excess revenue in some manner such as patient care:
…the dean, who is often responsible for the practice plan, reports to a senior university official, whereas the hospital’s chief executive officer (CEO) reports to an independent board of trustees, as is the case at the University of Maryland, where I work. Conflict among deans, among chairs of clinical departments, and between directors of practices and directors of hospitals, particularly over the distribution of resources, can be endemic in institutions structured in this manner.
The organization of the AHC will be challenged in another way as well. The structure of the clinical department is based on the university model developed in the 16th century. In this model faculty members who share a common knowledge are gathered in a department. This department is headed by a Chairperson. These departments are tasked with offering instruction in the unique content that the department faculty represent.
Chairs tend to be jealous of their prerogatives and are not naturally inclined to transfer the administration of their clinical services to a central authority whose aims may not coincide with their own. The effectiveness of ACOs will depend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model. At least currently, department chairs have few incentives to change from their traditional method of operating. Without such coordination, it will be difficult for academic medical centers to reduce the costs of practicing medicine — one of the principal aims of ACOs.
Another potential problem is the use of faculty physicians to supervise and deliver care. Faculty members in academic departments see their role, at least in part, as furthering global knowledge. The way this is traditionally assessed is when the faculty members receive grant funding and publish papers in peer reviewed journals. For faculty who teach history, this means going to the library and researching in the stacks then perhaps going out into the field. To some medical school faculty, this means treating patients in a unique manner. Unfortunately, for ACOs to work, the care, where possible, must be standardized.
Such standardization is not characteristic of the work of many clinical faculty members, who may have their own ways of diagnosing and treating patients who have similar diseases. Furthermore, doctors must accustom themselves to working with teams of auxiliary personnel to optimize their patients’ care, particularly for chronic conditions.
The traditional mission of AHC—teaching learners the nuts and bolts of clinical medicine—doesn’t pay very well. As ACOs proliferate, the anticipated efficiencies will eliminate some of the fee-for-service excess revenue that was being used by AHCs to accomplish this mission. Unfortunately, there doesn’t seem to be any obvious replacement for this revenue at this time. Additionally, the ACO is intended to change the balance in the health care world. As opposed to other industrialized countries, America has a health care system that is specialist dominated. Many have speculated that this is a contributor to the well documented high cost and poor quality of care. This will be a problem for AHCs.
It is the specialists, not the primary care providers, who dominate academic medical centers and order the expensive tests that increase hospital charges. Moreover, many patients are referred to academic centers for single-encounter diagnosis and treatment of one particular medical problem and not for long-term care, which is a key focus of ACOs. The requirement for robust primary care programs will present a problem for many, perhaps most, academic medical centers that propose to become ACOs. Centers that do not have large primary care programs staffed by full-time faculty or that decide not to develop such units will need to form alliances with off-campus groups of primary care providers, many of whom may be self-employed — an undertaking with which many centers will be unfamiliar.
Ultimately, AHCs may find that they have a niche that doesn’t require affiliation with an ACO to take advantage of the ACA (PPACA). Their hyperspecialization may be useful to patients on a contracted basis for care such as transplants or treatment of rare illnesses. However, if AHCs remain tasked with training physicians-to-be with learning bread and butter medicine, they had better find a way to bring learners and these types of patients together. ACOs are potentially one such way to do that but it will require the AHC to change, not the other way around.