ACOs and #OccupyHealthcare: Connecting the Dots

By Gregg A. Masters, MPH

Can you feel it?

“There is a great disturbance in the Force” | Emperor Palpatine in The Empire Strikes Back

At least two macros have placed this convergence experience in motion:

1. the March 2010 passage of the Patient Protection and Affordable Care Act, et sequelae (i.e., the final rule on ACOs and the Medicare Shared Savings Program);
2. the TweetChat #OccupyHealthcare on Novermber 6th, 2011.

While a material scale and magnitude differential exists between the two they are none-the-less intimately linked in our broader culture of innovation and transformational converations. Our healthcare ‘house of cards’ is perilously close to imploding of its own weight, inefficiency and absurd complexity.

The Federal deficit can not be addressed unless spending on Federal health programs can be effectively captured and restrained. That fact is no longer subject to ideological disagreement. Where we disagree is in the strategies and tactics to design and implement a cure.

The context for this consideration is in the midst of a growing albeit powerful message associated with the #OccupyWallStreet conversation which is playing itself out globally and is no longer a US-centric exercise.

On November 6th, 2011 a landmark TweetChat attracted a wide spectrum of the social media community and generated a fair about of web impressions via a dense transcript of ‘conversation’, click here for summary and stats. The home of this nascent ‘movement’ can be traced to the blog OccupyHealthcare.net – check it out if you want additional context, mission, organizers, ‘business case’. etc.

If I may summarize, the key argument for the #OccupyHealthcare movement is America’s ‘sick-care non-system’ isn’t working. It’s top heavy, too expensive, inaccessible to many, overly hierarchical, siloe-ed, not patient-centric (institutional mission mantra’s notwithstanding) and seriously lagging the adoption of key technological innovations including the meaningful use and sharing of health information, and role of social media to ameliorate if not remedy many of these deficiencies.

Enter the Accountable Care Organization, Primary Care Medical Home or Accountable Care Enterprise

To be clear I’m not talking about the arcane eligibility, legal entity or risk sharing provisions, etc., of the recently finalized rule, but lets roll this one back some 30+ years and examine the genesis of the HMO and the rather compelling arguments for coordinated, integrated or managed care.

To the extent the HMO represents ‘best in class’ health wonk implementation thinking to effectively tame the rapacious appetite of a determined healthcare borg, some 35 years since the passage of the HMO Act, the results have been, well rather ‘mixed’.  This ‘result’ is for good reason and upon analysis at no point can the wisdom of HMO design be seriously challenged if properly nested in group practice culture and administered accordingly. What stood in the way were corruptions of the business model from a non-profit community based enterprise to a series to for profit conversions by companies thirsty for expansion and market share gains. These companies grew aggressively via acquisition and roll-ups of mostly unrelated, discrete and non homogeneous HMOs by the major health insurers, i.e., Aetna, Cigna, United, WellPoint (Anthem/Blue plans).

Today, while you don’t hear much talk about HMOs, you do hear a lot of conversation on ‘accountable care’, ‘ACOs’ or even primary care medical homes. Yet, the same principles inherent in ACOs are the foundation and life blood of HMO managed service delivery and finance.

So lets revisit the charge to control costs, improve care and increase access via an evidenced based and patient centric health care enterprise. That formula to me can be represented as follows:

OccupyHealthcare precepts + indicia of accountable care x patient centric mission + accessibility / value  = ACO

These are not new ideas, nor concerns…the difference is at 17.5% of GDP the ‘business as usual’, i.e. show up and collect a paycheck crowd, has fewer and fewer supporters other than the weight of its own unsustainable momentum. What’s unclear is what comes next?

I hope this makes sense. If not, please share your thoughts.