Vol. 67 May 15, 2012 Our Health Care System: A Symphony Orchestra or A Herd of Cats?

May 15, 2012

 AMA chief executive James Todd, MD, jokes that leading physicians is like herding cats. Princeton health economist Uwe Reinhardt, PhD, compares it to making eagles fly in formation.  – AMA News, 1993

Two well-known analogies of our health care system came to mind the other night while I attended a concert of our local symphony orchestra.

The “symphony orchestra analogy” originated, or so the story goes, from the tension between a hospital administrator struggling with rising costs and decreasing reimbursement and the hospital’s Board. The Board Chair continually challenged the administrator to increase efficiency and reduce costs. The Board Chair also happened to be on the Board of the local symphony orchestra. One night the hospital administrator attended a concert, and wrote this letter to his Board Chair the next day:

“I enjoyed the concert last night very much, and you are to be congratulated on your effective stewardship of this important asset to our community. However, I couldn’t help but notice that the French horn players only played about 17% of the time. Surely they could be playing other instruments at other times with a little cross training. The two soloists, one alto and one soprano, seemed very underutilized. They only sang during the third movement. It seemed a wasteful use of your most expensive professionals by having them just sitting there gazing at the audience for most of the time. The forty violinists were impressive, but surely you could have gotten along with 35 or even 30. The drummer seemed to be the most efficient and was obviously cross-trained. He played almost all of the time by having a triangle, castanets, and car horn to fall back on when not beating a drum. Finally, couldn’t a less expensive automated device replace the pianist’s page-turner?

I am sure that you could probably cut 10-15% of the orchestra’s budget if you just implemented these logical changes.”

Just re-reading this and substituting “gastroenterologists” for “French horn players”, “cardiac surgeons” for “soloists”, and “primary care physicians” for “violinists” belabors the point.

The parallels between the musicians in the orchestra and physicians are more numerous than you might think.

Both are highly trained over many years. Both are said to practice.
Both are highly specialized. (one instrument or one organ system)
Both have to prove their competence. (auditions or licensing and credentialing)
Both are independent professionals that may periodically play together. (a concert or cardiac surgery)
Both get specific instructions for performance ( a musical score or practice guidelines)

What then is the big difference between musicians and physicians? Besides their pay scale (thay difference may be smaller now for primary care physicians), the big one, right off the bat, is that the musicians in an orchestra have a CONDUCTOR to help them play together.

Who can help the health care professionals to play well together? The Federal government? Clearly Congress has said “No”, even to a highly qualified physician “conductor” like Donald Berwick, MD. And, of course, the orchestra conductor is leading music that was written by someone else. (Congress?)

Are we left with just “herding cats?”  The Affordable Care Act calls for the creation of Accountable Care Organizations (ACOs) to improve quality and reduce costs. An ACO may include physicians (cats), hospitals (dogs) and patients (rabbits). Can they work together to work with, and even protect themselves from, the wolves (health insurance companies)? The first 27 ACOs designated by the federal government have been mostly physician-run, only a third of them even involve hospitals, and they cover a very small number of patients. The next round of 90 ACOs to be designated on July 1 will give us a better idea about this attempt to “herd cats” regionally and a better view of any potential impact on our health care system.

In the meantime, the music plays on.

Oops, there I go mixing metaphors.

But that may be “the answer”. Our health care system is just that, a really mixed up metaphor.

Vol. 65 April 15, 2012 First ACOs Appear with a Whimper, Not a Bang.

April 15, 2012

Medicare just released the names of the first Accountable Care Organizations (ACO), a major innovation of the Affordable Care Act (ObamaCare). ACOs apply to and are approved by the federal government as participants in the Medicare Shared Savings Program :

“All ACOs that succeed in providing high quality care – as measured by performance on 33 quality measures relating to care coordination and patient safety, use of appropriate preventive health services, improved care for at-risk populations, and the patient experience of care – while reducing the costs of care – may share in the savings to Medicare.”


 In the world of health care providers there has been much consternation, gnashing of teeth (maybe other body parts too), and exuberant, expert speculations about what an ACO was going to look like and by what means  the ACO program was going to “revolutionize American medicine” as promised by Washington.


 The first 27 ACO’s are surprisingly underwhelming. None of them have been developed by the “big boys” with name recognition in the medical marketplace, unless you happen to live in Caldwell County, North Carolina, coastal Georgia, or Hackensack NJ . Half are small physician-led organizations. Less than half appear to involve hospitals. All totaled they cover less than 1% of Medicare patients. Only two of the twenty-seven are willing to take limited risk of losing money (“going over budget”) in return for the potential of sharing in more savings (“providing care under budget”).

Medicare beneficiaries (patients) will continue to be able to see ANY provider and unless the provider boasts about it or otherwise publicize it, the patient may not know that his or her physician is a member of an ACO. In my local community the physicians organization took out a full-page ad in Sunday’s paper to “congratulate” themselves on being selected as an ACO. This particular physicians organization has had a contentious business relationship with the local hospitals for ten years, plans to cover only the minimum of 5,000 Medicare patients, and finds itself in competition with a recently spawned physician-hospital organization.

Another physicians organization formed just this year in a neighboring county plans to cover 6000 Medicare patients and does not involve its community hospital. The hospital itself is in a fierce, cost-cutting competition with a larger hospital up the road  just 15 miles closer to the academic medical centers who are courting it for a merger.

Both situations illustrate how complicated the medical/political/economic environment is for these initial ACOs.

Is this meager initial blossoming of ACOs due to bureaucratic complexity and uncertainty,

(“In conjunction with the final rule, the Department of Health and Human Services Office of Inspector General, the Department of Justice, the Federal Trade Commission, and the Internal Revenue Service issued separate notices addressing a variety of legal issues as they applied to the Shared Savings Program.  These included the interaction of the Shared Savings Program with the federal anti-kickback, physician self-referral, civil monetary penalty (the fraud and abuse laws) and antitrust laws, as well as the Internal Revenue Code regarding the tax implications for nonprofit entities seeking to participate in ACOs.  The final rule, the notice of the Advance Payment ACO Model, and the regulatory guidance on fraud and abuse were published in the Nov. 2, 2011 Federal Register.”)

 OR does it herald the appearance of an actual “new model of lean and mean care organization led by entrepreneurial physicians”,

 OR is it just one more step in our historically incremental evolution towards a system of universal health care?

Maybe the next 150 ACOs to be announced in July 2012 will give us more of a clue.

Stay tuned.

Vol. 43 April 15, 2011 “I Told You So”

April 15, 2011

“The [U.K.] proposals draw heavily on market-style incentives to drive improvements in outcomes and increase responsiveness to patients and the public. But they also include new arrangements for accountability, fundamental changes to the structure of the NHS, and a shift in the responsibility for paying for health services to groups of capitated physicians. (1)

Sound familiar?  Those words describing the current British health care reform effort could serve as a description of U.S. health care reform and the creation of Accountable Care Organizations (ACO). I know I bill myself as an “evidence-based” blogger, and therefore distant from the personal ranting, either angry or self-serving, by other bloggers, but this article in the New England Journal of Medicine spurs me to electronically shout out in triumph, “I told you so!”  In my blog (2) and in a paper (3) I wrote in 1967 (when?) I opined that  there seemed to be more similarities than differences between the U.K. and U.S. health care systems.  This well-researched article in the NEJM  agrees with me.

BOTH the U.K. and U.S. reform acts:

Seek to reduce costs by making providers accountable for total per capita health care costs ($32B less for U.K.over 5 yrs. and $100B less for U.S over 5 yrs.)

Seek to strengthen primary care

Remove payment incentives to increase volume of patient visits (Pay for “value” in U.S.;  “fixed budget” in U.K.)

Do NOT require providers to “bear risks” for  catastrophic illness like insurance companies do now (but that is an option for ACOs in U.S.)

Primary Care Physicians (PCP)
While the U.S. pays lip service to strengthening the PCP, the U.K. proposal really means it. U.K. will give the general practitioners CONTROL of over 70% of the NHS budget! The GPs will form primary care groups called GP Consortia. These Consortia will buy additional care for their registered patients from hospitals and specialists competing for contracts. 170 Consortia have already been formed and another 100 are being planned. A physician-run ACO in the U.S. would be similar, but the ACO would include both primary care and specialty physicians like present day multi-specialty groups. No one knows how many ACOs will be developed, and many of them will be formed by hospital systems.

Commentators on both sides of the Atlantic have voiced concerns that physicians will not be able to deal with these new managerial responsibilities successfully; physicians in neither country like to develop budgets, live by budgets, or even value management/administrative skills.

Quality Incentives
In the U.K. the National Institute for Health and Clinical Excellence (NICE) will set care quality standards for the Consortia and the contracts they grant  or “commission”. The Center for Effective Research (CER) established by the U.S. Affordable Care Act will have the same role of issuing standards of care. The practice of setting national targets for care  will be dropped in the U.K. to be replaced with “a system of open reporting of data on performance and clinical outcomes.” This newly available data will allow patients (“the market forces”) to choose high quality care among the “any willing providers” in the absence of national targets and differential prices. As in the U.S. there is little evidence that patients actually use such data when it is available to make decisions about where to seek care.

Two Big Differences
The U.S. ACO incentivizes coordination of care between primary care, hospitals, and specialist physicians. The U.K. Consortia will control the money and issue contracts for hospital and specialist services. This could increase competition and hinder collaboration in the U.K.

U.K. patients will still have to register with one GP though they will have more freedom of choice of GP, i.e. patients will no longer be restricted to registering with the closest GP to their home.  ACO patients will be assigned based on “previous patterns of care” though there will be incentives to use “participating providers”.

What are the take home messages?
We are not the only country muddling through a major health care reform while walking the line between regulations and market forces.

Everyone seems to be seeking the goals of higher quality and lower costs through electronic information upgrades.

Given the similarities between the U.S. and U.K. systems,  the charge that Dr. Don Berwick, Head of CMS and a pediatrician, “likes the NHS too much” seems a bit ridiculous.


1. NEJM 364:14, April 7,2011, p.1360-66
2. http://www.hubslist.org, Feb. 1, 2011
3.Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.

Vol. 38 February 1, 2011 Health Care Reform in the U.K. and U.S

February 1, 2011


“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw

In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.

Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.

Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996,  such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.

Accountable Care Organizations (ACOs)
In the U.K. regional Primary Care Trusts (PCTs) have been responsible since 1948 for “commissioning” (purchasing) care beyond primary care; hospitals, specialists (consultants), ambulance service, maternal health. GPs advised these trusts, but did not run them. By 2013 they will. 141 GP Consortia will commission (purchase by contract) all patient care services for a defined population and will control the allocation of 80% of the NHS budget. Secondary care providers (hospitals and consultants/specialists) will be competing on quality grounds for the contracts. Prices will remain regulated nationwide by the NHS. Sounds like a physician-run Accountable Care Organization (ACO) doesn’t it? (Remember 50% of U.S. medical care services are currently paid for by our government; Medicare, Medicaid, VA, or Federal Employee Health Benefits).

Medical Home
Since most GP practices have been closely connected for years with visiting home care nurses, social workers, and other ancillary social services through the Local Health Authority and every patient needs to “register” with a GP, GP practices closely match the newly-coined U.S. definition of “A Medical Home”; i.e. a multidisciplinary primary care unit that manages, but does not provide, all aspects of the patient’s care. Now the GP referrals will more directly affect the flow of money.

HIT Investment
A $20M (million) program started in the U.K. in 2003 to develop digital patient records and hospital administrative systems outsourced to two national major vendors its imhas been poorly implemented  . The new plan calls for incentives for more local and regional initiatives from the Trusts/Consortia to move HIT along.
“Improving IT is essential to delivery of a patient-centered NHS”..a modular approach based on”connect all” rather than “replace all”.
The government proposals call for an NHS-wide “information architecture” set around standards, improvements in data accuracy, and the opening up of records to patients online. The NHS looks to saving $32B (billion) by 2015 by implementation of the revised HIT plan. There is a concern about the Trusts/Consortia having enough HIT expertise to do this is. In the U.S. the establishment of 70 Regional Extension Centers and HIT Workforce Development Grants will help implement the “meaningful use” of HIT. Neither the U.K. nor the U.S. plans have established national standards for connectivity; standards that need to be “transparent and centrally mandated” to reduce complexity. This lack of connectivity will be an increasingly vexing problem for both providers and patients in both countries.

Bottom line: Both U.S. and U.K. are evolving toward a similar mixture of public/private health care schemes from their different historical directions. They share common objectives and common problems., and neither country is finding the path to be particularly smooth. Since EVERY country’s health care system is different, and critics of health care reform on both sides of the Atlantic are whipping up fear of the “other system”, it is time to move on and expand our vision by trying to learn more from France and Germany’s experiences.

1. Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.
2. David J. Kerr, M.D., D.Sc., and Mairi Scott, M.B., Ch.B., “British Lessons on Health Care Reform” , September 9, 2009, at NEJM.org
3.Wachter R, Goldman L. “The Emerging Role of ‘Hospitalists’ in the American Health Care System”. N Engl J Med 335 (7): 514–7. 1966

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