They Shoot Horses’ Don’t They?

By Gregg A. Masters, MPH

Some may remember the movie ‘They Shoot Horses’ Don’t They‘ [caution: a rather graphic depiction of an exit]. The plot borrowing from the humane ‘taking them out of their misery’ [post injury] if you will, albeit in the context of certain determined dance partners ‘desperate to win a Depression-era dance marathon and the opportunistic MC who urges them on to victory’, strikes a contemporary cord.

Some might extend this desperation metaphor to our rather creatively change resistent healthcare industry, aka ‘healthcare conundrum‘, given decades of serial failure [or success depending upon your interest]. Yet, with Dr. Eric Topol’s recent publishing of ‘The Creative Destruction of Medicine‘ where among his many insights, he acknowledges with the weight of history on his side that:

innovation must come from outside the profession [of medicine].

Fast forward the frame and consider where we are in the health reform, re-design or collective business model or technology leveraged innovation theater. At best it’s a mixed bag of industry voices, direction and results. The first series of ‘tea leaves’ can be traced to the consideration process (aka theater} over the Patient Protection and Affordable Care Act afforded by the Senate Finance Committee hearing process. An excruciatingly painful event to witness, yet the battle lines where being drawn at that time.

Next came the release of the ‘Notice of Proposed Rule Making’ to implement the broad brush provisions in the Act (yes, it passed over the wishes of the ‘Hatch Enzi Gang of 42) specific to Accountable Care Organizations’. While some 1,300 comments where filed by healthcare industry stakeholders [can you imagine a more iterative public/private exchange?], the rule was then finalized incorporating many of the substantive objections submitted to CMS. Yet, even with the ‘adjustments’ to the proposed rule, the fact that AMGA, arguably one of the centers of excellence in medical group consciousness and therefore coordinated care delivery, remained on the sidelines was a puzzling and somewhat disturbing turn of events.

So here we are. The Supreme Court (see briefs here) is about to take on the series of constitutional questions posed with respect to the Act. None directly speak to the provisions of ACOs per se, other than the underwriting implications of undoing the mandate, we remain in a very much bi-furcated, if not divided reform minded community.

Yet whether the Act is struck down in part or whole, the horse [no pun intended] is out of the barn. The only question which remains, who will lead and from what ‘book of business’ or marketplace vantage point? Judging from activity in the private (commercial) market where announcements of payor/provider partnerships are announced seemingly with regularity, it’s pretty clear that whether the codified rules on Medicare ACOs and derivative programs (Pioneer, MSSP, etc.), remain in the custody of legal or regulatory detention or not, the market will march on.