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10 things predicted by the Simpson’s before they became “a thing”

There is a running gag over several years in “The Simpsons” television show about series of movies which included an action hero named “McBain.” Loosely based on a combination of Bruce Willis and Arnold Schwarzenegger, in the movies McBain’s nemesis is Senator Mendoza from some unnamed Central or South American 1980s drug cartel country. In one of the most “haunting” scenes, McBain’s long-term partner is shot as he is outlining his plans for retirement. In fact,he actually takes a bullet intended for McBain while showing a picture of his recently purchased retirement boat, aptly named ” Live-4-ever.”  McBain is shown holding the body of his fallen comrade, crying out “MEEEENNNDDOOZZAAA!!!!”

Federally Qualified Health Centers (FQHCs) have been around since the 1960s. They were modeled on a South African system for effective care delivery to the disenfranchised. One of the first was started not too far from me in Mound Bayou, Mississippi.

The health center model that emerged targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics in both rural and urban areas around America. It was a formula that not only empowered communities to establish and direct health services at the local level via consumer-majority governing boards, but also generated compelling proof that affordable and accessible healthcare produced compounding benefits.

Over the years the federal funding has been generous, though much of the funding comes from patient generated revenue (money for seeing patients).  The Centers are also eligible for grant money for facility development, staffing increases, and offsets for seeing the uninsured among other things. The funding streams vary quite a bit from state to state, with those in Alabama being more heavily reliant on federal grants and less so on patient care. Legislators loved them because they put money in local, impoverished areas. Republicans in particular loved them because of the “block grant” nature of the funding. The local folks were best able, so the saying went, to determine where the money could best be spent.

One of the goals of the  Affordable Care Act was to move the money from direct funding programs into programs where the money followed the patient. It was hoped that this would give patients incentives to seek more effective care. It clearly would cut down on shenanigans such as this criminal case in Birmingham where the CEO bought a building, leased it back to the FQHC, videotaped his assistant in compromising positions, and made off with $14 million of federal money. As outlined in an article today, this money was money NOT used to deliver care to homeless individuals, poor folks, and others in need for whom it was intended. In fact, though they were receiving money to care for the homeless, they created barriers of transportation and distance to keep the poor, sick folks away. This money then made its way to the CEO’s pocket.

The ACA, as designed, would allow all the poor, including the homeless, to use Medicaid for their healthcare needs. This would allow a patient to identify the best care for his or her situation. We, in Alabama, have chosen not to accept the law as designed. Instead we have allowed it to be implemented  in a manner inconsistent with the design. We allow those in charge of implementing the law at the state level as well as those in charge of local care delivery to siphon money off. Then, when the system fails, we shake our fists at the clouds and blame Obama.

 

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When I was growing up my sisters and I would play the “Are we there yet” game. For those of you who do not indulge, this game is played by getting in the car, allowing the adults to begin the journey, then about 5 minutes into the ride begin asking “are we there yet?” in a rapid fire fashion using the most annoying voice one can muster. The adult’s role is to sit and ignore the game as long as possible and, when the time is right (generally about 5 minutes in) turn to the back and say “WE ARE HALFWAY, NOW SHUT UP.” At that point, the game is over and, in my family car, generally transitioned to the pinching game (“Allen is pinching me”).

Our Governor’s journey through the changing healthcare landscape has been evolving. In 2010, while campaigning for Governor, he had some deeply held beliefs regarding the newly passed Obamacare:

I started laying the groundwork for Alabama’s rejection of Obamacare by pre-filing a Constitutional Amendment to prohibit any person, employer, or health care provider from being compelled to participate in any health care system. It also codifies Alabama’s 10th Amendment rights over this issue. I have real-world solutions that will result in affordable and accessible health care for all without bankrupting our nation or pushing us closer toward a government-controlled, single-payer system.

The Supreme Court decreed the Medicaid expansion part of ObamaCare to be coercive in 2013 (As an aside, for it not to have been coercive it would have had to meet the following criteria (1) related to the general welfare, (2) stated unambiguously, (3) clearly related to the program’s purpose, and (4) not otherwise unconstitutional.) 26 states elected not to take the expansion, preferring to stick with the (poorly funded, focused on wasteful inefficient care delivery) old program. Our Governor announced that we would be one of the states refusing the Medicaid expansion:

The Affordable Care Act–or ObamaCare–and Medicaid expansion is taking our nation deeper into the abyss of debt, and threatens to dismantle what I believe is one of the most trusted relationships, that of doctors and their patients. Essential to ObamaCare is Medicaid expansion–a federal government dependency program for the uninsured. …

Now they are telling us we’ll get free money to expand Medicaid. Those are your hard-earned tax dollars. Our great nation is $17.2 trillion in debt and it increases by $2 billion every single day. That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.

The good news is that his view continues to evolve. Over the objection of our state senators, he is now ready to accept Medicaid expansion IF there is a work requirement, along with a few other conditions:

“It would have to be in the private sector and there would have to be some requirements on it,” Bentley told reporters in December. One specific requirement he mentioned was that he’d like to see the system tied to employment. “(Recipients) need to be working on getting a job, or having a job.”

A couple of things, Governor, to consider before you start playing the pinching game with Senator Pittman. 72 percent of uninsured adults who are eligible for Medicaid coverage live in a family with at least one full-time or part-time worker. More than half (57 percent) of these adults are working full- or part-time themselves. The overwhelming majority of workers earning less than 138 percent of poverty—81 percent—don’t have coverage through their employer because their employer either doesn’t offer it or it is unaffordable to them.The Kaiser Family Foundation recently looked at the main reasons for not working among unemployed, uninsured adults likely to gain Medicaid coverage if their state adopted the Medicaid expansion. It found that 29 percent were taking care of a family member, 20 percent were looking for work, 18 percent were in school, 17 percent were ill or disabled, and 10 percent were retired.

Maybe we really are halfway there.

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“As you may know, a health reform bill was signed into law in 2010. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it?” (Kaiser Family Foundation tracking poll question)

The Affordable Care Act was signed into law in 2010. Most of its controversial provisions were delayed for 2-4 years, partly to allow the taxes to pay for the subsidies to ramp up and partly, I suspect, to put some distance between the passage of the law and the reelection of the lawmakers. The distance aspect was not nearly as successful as it could have been, as many folks developed a deep and persistent hatred for the law. Kaiser Family Foundation, a non-partisan group focused on health care access, has tracked public opinion since the law was signed. In April 2010, 46% of Americans viewed the law favorably, 42% unfavorably and 14% had no opinion. In March 2015, favorables have gone down to 41% and unfavorables have stayed roughly the same. In other words, opinion has not changed much in the past 5 years.

Part of the reason that people are ambivalent is that until they approach mid-life, their interactions with the health care system are limited. Half of all Americans spend less than $300 annually on health care. Basically, some folks may have noticed that their contraceptive method was a little cheaper (thanks, Obama) and some may have noticed a higher co-pay for their once a year visit for allergy symptoms (thanks A LOT, Obama). Once people hit 65, they are in the Medicare system. This system is being affected by changes in care delivery but not in a way noticeable to the average consumer. Even so, 46% of those over 65 view the law in an unfavorable light. (What, Medicare doesn’t pay for Viagra? THANKS FOR NOTHING, Obama).

Many changes in health care were put into motion prior to the passage of the ACA. These include efforts to improve Medicare quality (Bush), improved access through better funded community health centers (Clinton, Bush) and money for better health care information technology (Obama). With the ramp up to ObamaCare being several years, almost anything that folks notice that is different from when they previously sought care (What, no cough syrup for babies anymore? Damn you Obama!!!) is blamed on Obama.

This brings me to the story of my friend, John Waits. He is a rural family physician who lives in Centreville, Alabama. He has a wife, several (I believe 5) children, and a passion for rural medicine and for his adopted home town. I have known John for about 10 years, and he has consistently wanted to bring training to rural Alabama. Through a combination of a Bush administration program designed to improve access for the poor (expansion of community health centers) and a program included in the ACA designed to take money away from large hospitals and move it into communities where it can do the most good (Teaching Health Centers) he was able to do just that. Although the funding was through the ACA, the idea, like many included in the law, was much older and was a bipartisan idea.

The funding for the teaching health center side needs to be renewed, and so John has been speaking out a bit. Not calling attention to our lack of Medicaid expansion. Not calling attention to the fact that we only have one statewide insurer so no real competition. Simply asking our delegation to pull the Teaching Health Center idea from the ACA and make it a separate idea to allow him to continue to train doctors for rural Alabama, in rural Alabama. Al.com posted a nice story about it.

Someone forwarded me the story, so I sent John a congratulatory email: subject line, IGNORE THE COMMENTS. There are now 230 comments on the article at al.com. The commenters are projecting what they believe about the ACA onto poor John’s program, including at least one former patient who will not see him OR ANY DOCTOR whose boss is the “gummint.”

The lesson for all of us, I suppose, is to be like John and keep on trying to do the right thing. Read more about Teaching Health Centers (here is a place to start). Call your representative and ask for the Teaching Health Center program to be continued (it is currenty in the SGR repeal bill stalled in the Senate). Mostly, be like John and do the right thing even at some personal cost. And always: ignore the comments.

My wife: Why is Obama making people buy insurance policies that cost 8% of their take home and pay for “not much”

Me: Don’t blame me, I voted for “single payer”

My wife is involved in the enrollment process for the Affordable Care Act. Last year she enrolled many folks who were grateful for their newly found access to health care. This year she is finding a that many folks didn’t pay for health insurance previously because a) they are reasonably healthy and b) they realize that they are paying for, to coin an expression, crap.

What her clients, and everyone else in America, is painfully aware of is the following (complements of Dissent Magazine):

In America we spend a lot of money and get worse outcomes than folks who live in other countries. Some of our excess mortality is due to car accidents and gun violence but there is general agreement that even once that is accounted for, we don’t get our money’s worth. Why?

As a rule, we pay more than our peers for the same health care goods and services (especially drugs). Much “health spending” is wasted on administrative overhead, on marketing, and on the important business of figuring out who is insured and who isn’t. And that spending is starkly uneven, lavishing services on those with good insurance coverage and bypassing those without.

Here in Mobile, we finished celebrating Mardi Gras today. This is, in the words of my son, a very weird celebration. For 3 weeks, people eat, drink, and dance to excess. The streets are filled with vendors that sell such delicacies as fried Oreo cookies. The parades themselves feature folks throwing moon-pies by the thousands to the crowds. Today, tens of thousands of folks were out today cooking lots of meat over open flames and drinking lots of adult beverages.

Today was Mardi Gras day. It features a parade, the Knights of Revelry, with the lead float featuring Folly who, using pig bladders, calls attention to our excesses.

Mardi Gras 2010 096Then, at the end of the day, Folly reappears being chased by Death.

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Legend has it that, at the end of the parade, Folly wins out. However midnight invariably comes and Folly is put away for another forty some-odd weeks.

As my wife has discovered, we have been throwing the equivalent of a “carnival” diet for healthcare. We throw a lot of care at the wrong people and not enough at the people who need it. As a consequence, we are now requiring folks to spend up to 8% of their income or risk a penalty.

Here is Mobile, after today, moonpies will no longer fall from the sky. One has to fry ones own Oreo cookies if he or she has a hankering. The parade barricades go away. Perhaps people will demand more disciplined health care spending as well.

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Remember the song, “We’re # 37“? It came out in 2009, the beginning of the debate about the ineffectiveness of the American healthcare system and the need for change. The video went viral, more because of the catchy tune and cute visuals, I’m afraid, than for the message. Here we are 6 years later and even with the Obamazation of health care our system is still last in the industrialized world. We still do not offer access to all of our citizens (witness the 24 states that deny access to the working poor), Our system remains very inefficient with 30% of spending wasted on inefficiency and unnecessary care. We deny people access to measure proven to extend lives and do so in a manner that punishes those of color disproportionately. Worse, we do it in a manner that costs twice as much as other industrialized countries, with most of that money coming from taxpayers.  .

As a part of a class I am taking, I have been reading a lot about change management. This weekend, I read John Kotter’s book Leading Change. In this book he identifies 8 components necessary to change an entrenched system in the business world:

  1. Establishing a Sense of Urgency (people need to sense that the platform is on fire before they jump into the ocean)
  2. Forming a Powerful Guiding Coalition
  3. Creating a Vision
  4. Communicating the Vision
  5. Empowering Others to Act on the Vision
  6. Planning for and Creating Short Term Wins
  7. Consolidating Improvements and Producing Still More Change
  8. Institutionalizing New Approaches

Why are we still last? It appears that we skipped the first step. Most people never use healthcare at all. thus they are unaware that the platform is burning. Or, even if they do, it is for an urgent problem (my throat hurts, I have a cough) and our system is really good at getting folks in and out for self limited problems in a very expensive manner ($111 to tell you “It’s a cold, live with it“). For the 20% who need our system a lot, the system has moved most of the costs to the taxpayer, so the true costs are hidden. Of course, this is after the family has bankrupted themselves but the expression “blood from a turnip” comes to mind.

Turns out that part one of the Obamazation was “getting all people access” and that wasn’t even in Kotter’s book. Part two, “transform the system”, started last week. Sylvia Burwell, secretary of Health and Human Services, announced last week a series of sweeping Medicare payment changes.  In effect, the platform has been set on fire. The changes moving 50% of the money from fee-for-service to quality by 2018 with an interim goal of 30% by 2016. What does this mean?

[The adminstration] plans to tie 85 percent of all Medicare payments to outcomes by the end of 2016 — rising to 90 percent by 2018.

A subset of those payments — 30 percent in 2016 and 50 percent in 2018 — will have to be part of what the government calls “alternative payment models.” These are contracts where groups of doctors and hospitals and pharmacists — a big enough network, essentially, to cover a patients’ whole spectrum of health care needs — get a lump sum of money to take care of a set number of patients.

This, in addition to the 40% of commercial contracts that currently include a value component, means that over half of all dollars in health care will be contingent on quality. Is that smoke I smell?

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'I know I failed all the tests and never handed in any finished assignments. So what's your point?'Resident – You know that girl who just found out that she was pregnant and came to us around 26 weeks

Me: Yeah

Resident: Well she has a Hemoglobin A1C (measure of long term blood sugar control) of 11. Turns out she has undiagnosed diabetes.

Me: (Sigh) Go ahead and call high risk OB

The March of Dimes gave Alabama an F in the prevention of pre-term birth. That is not surprising in and if itself. We always get an F. In 2006, when 1 in 5 infants in Alabama were born before 37 weeks, we got a “low F.” At least this year, it was only 1 in 7. I guess that is an F+. In the United States as a whole, the number is a little over 1 in 10, putting us up there with Sierra Leone and Ghana and well below that of Cuba. Best state is California with a preterm birth occurring every 1 in 15 times. “Best practice” countries (the Scandinavian countries are the ones that do it best) have a preterm birth rate of about 1 in 20. The Alabama county with the highest (Bullock, 1 in 4, as a country would be worst in the world), through no coincidence, only has 4 primary care doctors, 2 dentists, and no obstetricians or hospitals that provide care for pregnant women.

Why does preterm birth matter? The vast majority of infants that die are delivered before 37 weeks; some die for no apparent reason. The more births beyond 37 weeks gestation, the lower the infant mortality. In addition, these infants are more likely to be admitted to a neonatal intensive care unit. March of Dimes anticipates that if Alabama were good at preventing preterm birth, we could save almost $500 million, most of it Medicaid.

You ask, why not just do what it takes? Saving half a billion dollars, improving the lives of almost 10,000 children in Alabama. Who could be against it?

Funny story, that. It was during the 1980s in the Bush 41 administration when we as a country identified infant mortality as a problem. Nationally, about 4 in every 1000 newborns were dying in the period of time between birth and 1 month of age. Some great thinkers and law makers got together and suggested that a lack of access to healthcare was a reason that these women were having early and unhealthy babies. In 1986, Congress passed, George HW Bush signed and Alabama Republican Governor Guy Hunt accepted a Medicaid expansion to provide care to pregnant mother because, well, “Won’t somebody please think of the children?” Today, almost 80% of pregnant Alabamians get prenatal care in the first trimester and 49 in 50 receive some type of prenatal care.

Fast forward 30 years later. We now know that, as I told my resident who presented this patient, by the time the woman presents for prenatal care, the horse is out of the barn. About half of all pregnancies are unplanned. Many women suffer from poorly controlled chronic illness that, should they become pregnant, can worsen pregnancy outcomes. Many woman are making lifestyle choices that can cause unintentional harm to their yet-to-be conceived infant but can be changed in a positive manner. To reduce preterm births we need to focus on pregnancy spacing, pre-conception counseling, addressing lifestyle choices that lead to poor outcomes, and planning pregnancy for those with chronic illnesses such as diabetes. There is a term “strong for surgery” that is gaining traction. Women also need to be “strong for pregnancy.”

This is a problem of primary care. We should provide preconception counseling to all women of child bearing age when given the opportunity. We as a society should provide access to primary care for all women of reproductive age (especially those with chronic conditions), and provide outreach to those with conditions related to poor behaviors to correct the behaviors before pregnancy. Our current President, a Democrat, gave us one of the tools (Medicaid expansion to women prior to conception) that is necessary if we want an A. It would still take a lot of work to get that A, as it almost always does. Just by accepting the expansion, we could easily get a gentleperson’s “C.” I suspect instead we’ll take the “F” in hopes that the next test will be on something easier, like football.

1_123125_123050_2279896_2300573_2302170_3_lineup.jpg.CROP.original-originalDoes the money to pay for this come from taxpayers held at gunpoint?

Comment on a forum about an upcoming meeting on the need for Medicaid expansion

Long answer: I am serving on a panel in Fairhope, Alabama to discuss the need for Alabama to accept the Medicaid expansion. Fairhope is a Victorian resort town on the bluff overlooking the Eastern Shore of Mobile Bay, about 30 miles from where I live. The town itself was first known as Alabama City but a group pf 28 folks from Des Moines, Iowa, purchased land in the area in 1894 and created a single tax colony:

The people who established Fairhope wanted to create a community that would, as best they could, implement the theories of economist and social activist Henry George. George wanted government to tax the full rental value of land, the value of which is created by community improvements and not by labor or invested capital. He felt that if the full rental value of land were taxed (including minerals under the land) that all other taxes could be abolished, thus becoming the single tax. Others termed his theories the Single Tax, and the name stuck.

The single tax corporation collects all taxes associated with property due to state and local governments and distributes them as well as administration and demonstration fees. These fees go to things that raise the value of the property for all. These projects include bayfront parks, a pier that goes a quarter mile out into the bay, the library, and many others. The Fairhopeans do indeed get value for their housing dollar. They also get waterfront parks.

The state share of Medicaid in Alabama is not paid for by a tax on property. In fact, very little of the tax dollars the state actually collects are used to pay for healthcare for the poor, as I have previously outlined. Though the people of Fairhope may want further the common good, averages Alabamian seems much more concerned about keeping their hard-earned in their own pocket. As such, they are seemingly willing to forgo 30,000 jobs and hundreds of millions of dollars of federal money to keep their own, personal, income taxes from going to someone who is undeserving. In the words of one commenter “Why should I work anymore if the government will give me everything I need?”

So, I will go and spread the word to the gentle socialists of Fairhope of the reality that corporations look for good community health when they relocate, along with the concern that, since the mechanism to fund poor people who become sick has changed, we are getting LESS federal dollars as a consequence. I feel certain that those in the room who are true Fairhopeans will see the need for them to look after their brother and, given that the federal dollars going into Medicaid ARE OURS ANYWAY, will nod their heads in agreement. I despair of convincing the people of the rest of Alabama that poor people are folks who get sick anyway, need care to prevent illness, and Medicaid is the only mechanism to provide that care. I can only hope they remember the wisdom of the Fram oil filter man, “You can pay me now, or, you can pay me later.”

From Kaiser Family Foundation, information found here

I have to admit that as a relatively healthy late middle-aged male, I don’t think a lot about my own death. My own physical exercise is undertaken, I guess, to stave off death as long as possible but as I suffer from no chronic ailments at this time and come from a very long-lived gene pool, I would rather focus on  other things.  I am a little worried that “they” want to take away my Medicare but don’t dwell on my upcoming but distant 7th decade at this time. The discussion over the “sustainability” of Medicare has downplayed the provisions in the Affordable Care Act that should lead to reduced cost in Medicare, discussed here. Instead, the discussion has focused on the House proposal to give patients a sum of money (tied to the consumer price index so effectively being reduced every year)  under the assumption that “the market,” when unregulated, will lead to better, less expensive health.

I found myself reflecting on life, death, the human condition, and the health care market today while reading the paper. There was an article about “medical tourism,” but not the good kind. This author interviews the mother of a gentleman who died. He was paid for a kidney (perhaps why God gives us two, kind of a savings plan for poor people who in their time of desperate need can have $5,000 US “withdrawn” from their back) but unfortunately died post-operatively. The recipient, after returning to the US, also died of complications of the procedure.

Per this article:

For decades, wealthy Brazilians, Mexicans and Saudis have gone to U.S. and European hospitals for medical care they couldn’t get at home. In the past decade, that pattern has changed. Hospitals from Puerto Vallarta, Mexico, to Medellin, Colombia, now lure middle-class Americans with promises of high-quality care at a fraction of what it would cost them at home.

Medical tourism company MedToGo, based in Tempe, Ariz., says it will offer kidney transplants in Mexico and Costa Rica for about $50,000, a fifth of the cost in the U.S.

In the illegal organ trade, brokers scour the world’s slums, preying on the poor with promises of easy money in exchange for a kidney.

In Colombia, 321 foreigners got transplants from 2005 to 2010, according to the country’s National Health Institute. Juan Lopez, a doctor who oversees Colombia’s organ transplant system as director of the NHI, says many of these surgeries are driven by profit for hospitals, doctors and brokers.

Turns out that a poor person from the slums is willing to sell a paired organ (a kidney, for example) for what seems like a lot of money to them ($5,000) and a non-poor person is willing to pay what seems like a reasonable amount of money ($150,000) for that same organ. The market works, and not in a way that makes me feel good. I am afraid that the Title Pawn industry will have nothing on the organ procurement industry when it comes to market forces and unsavory behaviors. I am convinced that vouchers will not lead to a reduction in health care costs. On the contrary, it will lead to more folks seeking out more health care as they approach death and are made promises that will never be kept. It may result in  people entering into contracts which reduce human dignity and increase the suffering of others.  People in ill health who are desperate will not only supplement their vouchers with their personal fortune, but will potentially pay with their shortened  life as the burden of iatrogenic illness increases.
The Affordable Care Act includes strong market regulation. The market prior to the passage of the Affordable Care Act, although poorly regulated, at least had sufficient regulation to prevent trafficking in human organs. When our friends return from another country with their brand new kidney, will we congratulate them on getting quite the bargain? If vouchers were enacted for Medicare, would we allow those who can afford it to get the same bargain here?

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.

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