Margaret Paroski, MD
A neurologist, Dr. Paroski is an executive vice president and chief medical officer of Kaleida Health, which serves more than 1 million patients in the western New York area. She is a former interim dean of the University of Buffalo School of Medicine and Biomedical Sciences.
When physicians take a look at how they get paid for something, it has little to do with how well they do it. The insurer determines the rate paid for providing a particular service in a given geographical area. From the perspective of the patient, after their co-pay, choice is driven by the three A’s: are you available, are you affable, and are you able? Because it’s the factor that patients can least judge, “able” runs a distant third.
Accountable care organizations represent a renewed effort to quantify the quality of care physicians provide, finally expanding on the “able,” while trying to keep health care costs down. But quality health measures are in an embryonic stage. As a neurologist, if seizure frequency is used as a measure of quality of care in epilepsy, I have to consider that some of my patients, by the nature of their disease, have frequent seizures. The amount of medication they would need for total seizure control would leave them grossly over-sedated. Does that represent good quality? Or should we also look at their quality of life? If a teenage patient whose seizures are best controlled on valproate becomes obese on the drug, she may find that totally unacceptable. Should I push her to take a drug that makes her miserable? Recognizing, creating and implementing good quality measures is very difficult and, in the case of chronic disease, we have fallen short.
Although hospitals care for patients at their sickest and most expensive, increasing emphasis is being placed on the physician’s office as the epicenter of health care. With ACOs, primary-care doctors are going to find themselves back in the driver’s seat, a situation similar to the move toward capitation in the ‘90s.
Primary-care doctors are now going to be driven to more closely inspect the quality of care their patients receive from other providers. If held responsible for risk-adjusted total annual health care costs for their patients, they are also going to want to select less-costly consultants and hospitals and eliminate unnecessary or marginally effective care. Doctors are familiar with discounts negotiated by insurance carriers as big groups, but it has not been a particularly personal experience. This may now change.
There is also increasing awareness of how much patients’ lifestyle choices impact chronic illness. Health insurance costs the same regardless of the risks these lifestyle choices cause. Individuals are not incentivized to have a sense of responsibility for their health. Physicians will increasingly be paid based on how effectively they can motivate patients to adopt a healthy lifestyle and comply with care. We need to further address this issue as a nation if we are truly going to bend the cost curve in health care.
ACOs and other recent health care reforms are another step toward reconciling our definition of the value of care received with our patterns of providing care. Whether they will arm physicians with the sufficient tools for success is still up for debate.
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