Editor’s Note: This idea started with a tweet last weekend by Dr. Terri Lewis, who has been writing for and speaking about how the health care system fails the chronically ill patient, in particular. We asked her to write about this for The National Pain Report .Dr.Lewis is the daughter and the mother of persons who suffered and suffer from chronic pain.
A basic premise of the Affordable Care Act (ACA) is that preexisting conditions will not result in denial of care. Theoretically, the formation of networks can insulate costs of care from runaway costs assigned to the minority of users who consume the greatest portion of total plan costs.
How well is this working for persons whose complex health profile includes chronic pain care?
Historically, physicians have not been employees of hospitals. Until the 1990s, the majority of physicians were members of independent or solo practices who enjoyed practice privileges through local hospitals. Since then, waves of hospital mergers have created metropolitan hospital organizations that have formed monopolies by purchasing physician groups. In rural areas, insurance companies have formed monopolies by controlling the enrollment of providers and capitating the numbers of specialties who can participate. Between hospital mergers and the formation of hospital owned health insurance groups, physicians are integrated vertically into health care systems in a new configuration ostensibly designed to improve care and reduce costs. While this seems like a useful approach to improving care while reducing cost for expensive patients under the Affordable Care Act (ACA), things may not be what they seem.
The ACA was designed around the premise that Medicaid would be expanded to supplement reimbursement for persons under a certain income threshold. At this time 19 states still have not adopted Medicaid expansion, creating a significant community coverage gap. Despite this, the ACA incentivizes health plans to form narrow networks, a strategy encouraged by CMS regulations. Some definitions-
Medicare Shared Savings Program (MSSP) is the set of CMS guidance regulations located at the link below.
Accountable Care Organizations (ACOs) are groups of providers (hospitals, physicians, other providers) who join together for purposes of a Medicare fee-for-service incentive program. ACOs are paid to “reduce costs” for treating their patients. While this seems like a reasonable goal, the ACO system has a number of risks-
- Some plans allow the consumer to pick from a menu of alternatives ACO plans based on what they believe their needs will be. Annually, the consumer can change their plan assignment and may have to change physicians as a result.
- Most consumers don’t “enroll” in an ACO – they are assigned to an ACO based on the patterns of their utilization. At the end of the year, if a patient happens to have had a bulk of their care (measured by either service counts or dollars of Medicare claims), from physicians who are members of a particular ACO, then that patient is assigned to that ACO.
- Not only do many patients not enroll in ACOs; they might not even be aware of them, as assignments may take place after the fact.
- ACOs receive bonus payments based on the total amount Medicare pays for care of those patients. That total includes allcare those patients receive from all providers – specifically, including providers who are not members of the ACO. Bonuses are based on reducing total costs relative to what would be expected using a risk-adjusted cost based on each patient’s health status. Here, reduced costs mean reduced services or, less care.
Providers are incentivized to encourage patients to utilize less care – say, to recommend fewer surgeries, fewer hospital stays, less frequent follow-up visits, and so on. ACO participants can refer patients to other participants in the same ACO when another type of care is needed, so that the ACO can deal with the patient in a consistent manner. There is no follow-up by the ACO to determine whether care alternatives achieve necessary purposes because they are measuring reduced utilization not better outcomes to care. Patients are left to their own devices to manage these processes without the substantive information necessary to make truly informed choices about their treatment.
How is an ACO is supposed to reduce patients’ utilization of health care in a fee-for-service system?
- ACOs control the number of providers who can participate in the provision of services within a geographically bounded area.
- Where the ACO controls a large percentage of the available providers, it gets a lot easier to reduce patient utilization by controlling provider participation. ACOs that “own” most of the specialists in a geographic area have a much easier time controlling utilization.
- Providers who serve large numbers of complex patients may be denied the opportunity to enroll, forcing their patients to redistribute to other practices, or leaving them without a reimbursable service entirely. ACOs that have met their capitation objectives are unlikely to admit additional physicians who might provide more appropriate care for specific individuals.
- It becomes a lot easier to guide patients to the level and type of utilization desired – which is, for purposes of the Medicare Shared Savings Program, always less
- It is easy to enforce referral and utilization policies on physicians who are employees of a group running the ACO, rather than simply independent businesses who happen to join an ACO at a given moment in time.
- ACOs that want out of certain lines of business they perceive to be risky can simply cut those services from their menu of care by delisting physicians.
In other words, the Medicare Shared Savings Program encourages hospitals and physicians of different specialties to join together in order to encourage patients to use less health care.
How does the patient fare under this scheme?
- Because ACOs control the number and type of physicians who participate, providers may not have specialties that match the needs of the populations to be served, which forces patients to seek treatment outside the system on a cash basis. Where there are no funds, there is of course no reimbursed service.
- There is no requirement under the ACO for the enrolled physician to accept eligible patients with complex care needs. To be eligible for bonuses, physicians find themselves managing their overall patient risky profile of services across their practice rather than managing the care needs of patients.
- Patients with long standing physician relationships may be forced to change providers when they are denied the opportunity to enroll. This forces patients to redistribute to other practices in order to seek care from someone unfamiliar with their history and needs.
- The lack of a physician may force the patient to seek services from local emergency rooms which leaves complex care patients vulnerable to less than appropriate care. Continued care failure at the ER level may result in wrong diagnosis, under treatment, and cause the patient to refuse to seek necessary treatment entirely. This can result in patient stigmatization, labeling, and other negative consequences such as lawsuits lodged against patients who cannot afford hospital fees.
- Rural ACOs “own” most of the specialists in a geographic area control utilization in ways that may result in less than optimal care because the specialists may have no experience with a patient’s health condition.
- Patients are rarely informed about the conditions of participation for their treating physicians who have affiliated with ACOs.
- The responsibility to find appropriate physicians within this scheme is left to the patient – there is no obligation for the ACO to modify their practices to insure that enrolled are served.
- The boundaries of the ACO configuration may require patients to travel very long distances for care, undermining the very premise of affordable, accessible care provided where and when needed.
- Patients with chronic pain may find themselves lost at sea in this system of reduced care as state pain laws redirect precious services and require more frequent interaction with their treating providers – a direct conflict with ACO requirement to reduce utilization.
Who manages this system?
CMS is responsible for Medicare portion of ACOs. State Medicaid agencies are responsible for administering contractor ACOs under the Medicaid portion of this plan.
What about drug plans?
CMS administers the drug formulary. Drugs are dispensed according to the purpose for which they were approved by FDA. This is referred to as ‘covered uses.’ State Medicaid plans adopt the formulary. Patients may have to adopt prescriptions that are less than optimal depending on how the ACO chooses to administer their portion of the plan. An appeal process is available but lengthy and difficult for the patient to manage. Medicare will not provide patients with information about covered uses, which makes it difficult for both patients and care partners to develop an appropriate medication plan. Multiple appointments may be necessary to deal with this issue, placing the individual at odds with the physician’s risk ratio requirements.
So, let’s take a real example.
Patient X is 33 years old, assigned to a Tennessee operated ACO as a dual eligible, receiving both Medicare and Medicaid. Dealing with a lifelong spinal injury, his needs are complex. Given his complexity, he finds dealing with physicians to be a consistently unsatisfying interaction. Having already had three major surgeries, he requires a fourth due to broken hardware installed during his third surgery. He will require monitoring, future surgical procedures, pain management, behavioral health, and lifelong wellness supports.
New to the ACO, his surgeon requires primary care support, pain management, behavioral health support, and smoking cessation as preparation for a pending major surgery. On his own, he makes multiple phone calls to attempt to obtain a primary care physician to coordinate a program of care with his surgical center – a major hospital 100 miles distant. Unknown to him, the ACO has capitated physician enrollment within his service area. Available primary care physicians have in turn, limited the number of patients they will see attached to his ACO in order to manage their risk ratios. This allows them to allocate risk across their patient group and preserves their ability to be eligible for bonuses. No primary care physician associated with his ACO will accept him for care. Unaffiliated primary care providers will assess him $220.00 per visit out of pocket. On Social Security disability, that is not affordable. His public health clinic will not prescribe for either his pain management or behavioral his health needs. His behavioral health center doesn’t treat people with chronic pain having no specialists on their staff.
His surgical needs are complex and urgent. Without primary physician support, he cannot obtain the care support he needs for coordination of services and pain management. Rejection of services is entered into his medical record as an inappropriate patient who is too complex to serve. State pain laws have resulted in rejection for appropriate pain management support for complex chronic pain management needs. In his state, under current regulations changes, primary care physicians will not prescribe for chronic pain; interventional pain management specialists will not accept a patient who (properly) rejects interventional pain procedures.
Eighteen months into this situation, this individual filed complaints with CMS and state Medicaid over their failure to manage the ACO contractor for the state in which he lives. Persistent phone calls over a four-month period resulted in a telephone meeting to assign service providers. From this a primary care provider 100 miles away was identified. The primary care provider is co-located with a behavioral health care provider. After a first visit, both entities agree that their service is too far away to be useful to this patient but they can see him about every 3 months. Both entities refuse pain care management but make suggestions for a new palliative care provider (again 100 miles away) – who cannot provide services because his death is not imminent within a projected 12-month period.
No surgery will be performed without wrap around supports – it’s perceived as riskier than allowing this patient to remain underserved. Worse, nobody is held responsible for this design failure except this patient – who has absolutely no control over the outcome.
As Robert Book (Forbes, 2016) notes, “It is highly ironic that a law proposed, in part, because of the allegation health insurance companies were increasing their profits by denying care to patients – is now the means by which the federal government pays physicians to, in effect, deny care to patients.” In an arena of opiophobia and changing state regulations, the result for patients with complex care needs is exactly like lighting a match and flipping it into a pile of leaves.
Keep your ears pealed for this problem advocates. Now more than ever you are needed. My next article will address potential courses of action.
CMS (2015, December). Medicare Shared Savings Program Shared Savings and Losses and Assignment Methodology Specifications Applicable Beginning Performance Year 2016, Version 4 Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/Shared-Savings-Losses-Assignment-Spec-V4.pdf
Book, R. (2016) Why Are Hospitals Buying Physician Practices and Forming Insurance Companies? Retrieved from https://www.americanactionforum.org/research/why-are-hospitals-buying-physician-practices-and-forming-insurance-companies/
Book, R (2016). ACA ‘Savings’: Paying Doctors and Hospitals Bonuses to Deny Care to Patients. Retrieved from https://www.forbes.com/sites/theapothecary/2016/02/21/aca-savings-paying-doctors-and-hospitals-bonuses-to-deny-care-to-patients/#726420352064