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Sunday, April 3, 2011

Broadening the gainsharing of ACO's

I am about 100 pages into the ACO final rules. I am trying to get my head around how the risk/gain sharing as proposed will play out. However, it occurred to me that there is one constituency which has been completely ignored; patients. Why are they not part of the gain/risk sharing equation? Yes, it could be argued that they are an indirect part of the equation in that saving of the Medicare program will be passed on in the form of lower taxes....maybe.

Why not make them direct participants in sharing of risk or financial gains? There are lots of ways to structure such a program. If physicians receive a financial windfall from spending less money why shouldn't their patients share in that windfall? It can be implied that money saved is a consequence of withholding specific elements of care or substitution of low cost vs. higher cost interventions. Why shouldn't patients be involved in these decisions, specifically when it involves their care? They have much at stake and the reality is it is their money as well.

There are all types of circumstances where this might be deployed. If a patient elects to have conservative medical management for a problem which has also has an expensive interventionalist approach, why not share the savings with that patient? If a patient elects to use the cheaper statin drug (or perhaps elects not to take the drug at all), maybe it should be their financial windfall? Such a mindset might be very reasonable when we are dealing with NNT scenarios which are in the thousands. Would it be unreasonable for a patient to want the rebate instead of the drug which he/she has only a one in thousands chance of benefit from?

Deployment of such a program would almost certainly spur the development of an entire industry counselling patients regarding what types of treatments and tests to decline. Yes there is risk that patients might decide to forgo treatment which is recommended by their physicians. I think this is a certainty, not just a possibility.  I have no doubt that creation of gain sharing where patients have a chance to take the cash and not the care will result in many people taking the money.  However, in a world where patient autonomy is valued, where do we draw the line in terms of intervening when people with decision making capacity decide to deploy their own resources in a way we disagree with.  We simply need to be persuasive enough to convince patients that what we offer is worth the money they will forgo. It won't be easy to deploy and it will provide many gaming opportunities, but what else is new? Remember the alternative is what is presently proposed where insurers and providers collude to covertly ration care.

I wonder if the Center for Medicare and Medicaid Innovation would be receptive to this type of innovation? 

1 comment:

  1. It was surprising in the NNT article in Bloomberg, a financial periodical, that no one, not the authors nor the parties on either side of the issue, had done expected value analysis on outcomes of various, competing management strategies and their consequences. Expected value analysis is a fundamental tool for applying probabilities to the costs of mutually exclusive outcomes integrated over time to compare what, in nominal dollar values, is the least expensive alternative. NNT itself is a form of expected value analysis but is a static figure. I expect than none of the parties to the debate on the applicability of NNTs to medical decision making really want such a dynamic scoring of outcomes done as hard, if abstract, numbers would challenge their personal perspective in the decision making process on the value of therapeutic alternatives. If I were a patient though who was being counseled on, and given an economic stake or even incentive, in my decision to undertake a particular therapeutic approach, the first thing I would ask for would be an expected value analysis of the long term outcomes of the different alternatives.