By Dr. Jaan Sidorov

First Posted at Disease Management Care Blog on 3/13/2013

Dr. Jaan Sidorov, host of Disease Management Care Blog
Dr. Jaan Sidorov, host of Disease Management Care Blog

Anyone remotely interested in Accountable Care Organizations (ACOs), should be aware of this Wall Street Journal article by economist-savant Clayton Christensen on The Coming Failure of  ‘Accountable Care.’

Dr. Christensen argues that just because they’re in ACOs, a) physicians aren’t going to change their money-spending ways, b) without any corresponding “skin in the game,” patients will continue to demand high-end services  and c) the rosiest savings assumptions will still be minuscule compared to the total federal health budget.

If true transformation is needed, argues Dr. Christensen, health policymakers should embrace alternative care venues (“Minute Clinics”), downjobbing (let generalists provide specialty care services), non-physician providers (nurse practitioners) and telehealth.

The Disease Management Care Blog thinks Dr. Christensen has it mostly right about ACOs but has less confidence in his alternative solutions.

Minute Clinics: in classic health insurance 101, alternative care settings are not substitutive, they’re additive.  Classic economic supply and demand does not apply because most health care services create their own demand.

Downjobbing: in any health care system, the economics are push and pull: costs are avoided, while revenue is pursued.  While the luster of a rich procedure code is enough to drive patients toward specialists, another factor in patient referral patterns is the associated cost.  To put it bluntly, the ultimate value of primary care physicians is the savings that they achieve for patients who represent a cost.

Non-physicians: there are arguments on both sides, but health care ultimately remains a labor-intense environment.  The main argument unaddressed by Dr. Christensen is that playing concertos, flying fighter jets and getting diagnoses and treatment right more than 99% of the time requires 10,000 hours’ worth of expertise.

Telehealth: the same Minute Clinic logic applies: typical telehealth could end up being additive, not substitutive.

Jaan Sidorov, MD
Jaan Sidorov MD is the Host of the Disease Management Care Blog where he shares his knowledge and insights about medical home, disease management, population-based health care and managed care. He is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He is primary care by training, managed care by experience and population-based care strategies by disposition. The contents of his blog reflect only his opinions and should not be interpreted to have anything to do with any current or past employers, clients, customers, friends, acquaintances or enemies, personal, professional, foreign or domestic.


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