The Doctor Is In

Five, apparently.

What brilliant darkness now descends
To slay the weight which life doth rob
To bear the anguish undeserved
On frigid stone no glorious end.

What brilliant darkness now breaks bright
With light a sun can scarce reflect
To roll the stone which triumphs death
The lamps of countless souls to light.

Have a blessed and fruitful Easter. God bless.

Amazing — and in no small way, terrifying at the same time.

Of course this technology will only be used for the good of mankind…

And the hits just keep on comin’ from our enlightened masters in government-run health care:

‘Poster Boys’ Take A Pass On Pioneer ACO Program:

During the health care debate, the Mayo Clinic, the Cleveland Clinic, Geisinger Health System and Intermountain Healthcare were repeatedly touted as models for a new health care delivery system.

Now, they have something else in common: All four have declined to apply for the “Pioneer” program tailor-made by the Obama administration to reward such organizations.

“When the poster boys ask that the posters be taken down, you have a problem,” says Michael Millenson, president of Health Quality Advisors LLC…

The four health systems are considered the most promising models for “accountable care organizations,” a new approach to delivering health care services that rewards doctors and hospitals for providing high-quality care to Medicare beneficiaries while keeping costs down. The ACO provision became one of the most highly anticipated elements of the health care overhaul, and providers embarked on a frenzied race to join in as quickly as possible.

But when the proposed regulation for the program was announced in March, excitement fizzled.

Hospital and doctor groups complained that the program created more financial risks than rewards and imposed onerous reporting requirements. The American Medical Group Association, which represents nearly 400 large provider organizations, responded with a letter to CMS warning that more than 90 percent of its members would not participate because of the reporting requirements and financial disincentives. In particular, the proposed rule would impose penalties for ACOs that do not achieve savings.

In response, HHS announced the Pioneer program in May, promising it would “provide a faster path for mature ACOs” like the Mayo Clinic that would allow the high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk. HHS estimated that the Pioneer program could save Medicare as much as $430 million over three years.

The big boys in health care were so impressed by the latest-and-greatest rendition of Obamacare’s hot new ACO “reform” (which is little different than the disastrous capitated HMO model which went down in flames not so very long ago) that they responded, “Thanks, but no thanks.”

No doubt a new rendition of ACOs will be forthcoming soon, complete with a host of new regulations, onerous reporting requirements, and penalties for care which does not meet “quality” (AKA, low-cost) standards set by the government. After all, who knows more about “quality” than our sharp-witted wizards in Washington? Be afraid — be very afraid…

Centralized funding and control of health care is beyond disastrous. It is paving the road to national bankruptcy. The answer to this monstrous failure is, as always, more control, more regulations, more centralization. Sadly, like a runaway train, it hurtles down the tracks toward an inevitable trainwreck.

Let’s just hope and pray that there will be some salvageable pieces left when it all jumps the tracks. Physicians who have wedded themselves to hospital-based and other large ACO-aligned medical groups for security will find themselves among the wreckage.

The only hope for physicians in the long run is to move outside the current system of third-party payers and decentralizing toward a cash-based practice. The inevitable outcome of the coming disaster in health care (and no, our politicians won’t prevent it) is severe rationing of care, long waits for doctors visits, diagnostic studies, and surgery. For patients, catastrophic coverage (if you can get it) with HSAs will ultimately prove the safest and most reliable way to get access to health care.

Welcome to health care in the millennium.

It haunted him, without mercy.

Strong, athletic, handsome, and personable, he seemed at life’s outset to be unfairly advantaged. His friends were many; a ladies man, by reputation, the life of every party, the love of every woman who gazed on him.

He was, by nature, a generous and gentle soul, a gift he received from his parents, humble and devout. He himself found religion attractive, and attended synagogue regularly with them. He had little use for the priests and the lawyers––he found them legalistic, arrogant, and judgmental––but embodied in his faith he discovered a formula for living: obey the law of God, and your life will be healthy and prosperous. Did not the Proverbs promise, “By humility and fear of the Lord are riches, and honor, and length of days”? He would do his part, and God His, and all would be well in life.

The climb has been arduous. Stronger and more agile than his friends, he had reached the top of the cliffs before them. His best friend, struggling behind him, lost his footing, and he reached back to save him from falling. His friend was saved — and his own life changed forever.

When he came to, he felt no pain — in fact, no sensation whatsoever. He heard his friends scrambling down the cliffs and shouting; he tried to get up, but could not. He had survived the fall–and lived to wish he had not.

Weeks and months passed, with no improvement; his paralyzed body remained lifeless, though his mind, now a tortured prisoner, remained fully alive. Most of his friends drifted away, their discomfort in his presence so palpable that their absence was more relief than regret. The Four remained, though he saw no reason for them to do so, other than guilt, or some pathetic sense of charity to the crippled. His limbs withered and shriveled, twisted like the branches of those ancient trees on the cliffs. Racked by fevers, festering pressure sores, and wallowing in the excrement he could no longer control, he no longer had a life, but only a slow, agonizing, and hopeless descent toward death.

The Four visited him daily, alone, in pairs, and on occasion collectively. They cleaned him, tended to his wounds, and tried to encourage him in his deepening depression, to no avail. As shriveled and twisted as his body had become, his soul became far more foul and fetid in its unquenched and raging bitterness. Self-pity, self-loathing, and a hopeless despondency descended on him, crushing and torturing his spirit in a living personal hell. His friends prayed, and read Scripture, and feigned faith in some deliverance of spirit, if not body; it only increased his cynicism and the sputtering rage he spewed toward God. How could a good God allow such an evil fate? Had he not kept his part of the bargain, only to be betrayed by a deity he had once trusted? Why did his friends torment him with this utter nonsense?

Then there was the humiliation he suffered at the hands of healers, who prayed and pranced and called down Heaven’s power to heal him; he had too little faith, they accused, when their futile foolishness failed. In this, they were most surely correct. Then, the day his friends dragged him to the Temple, to the priests, as Moses had prescribed. His bondage arose from hidden sin, they said: his own, or his parents. What sin was this, he challenged? The sin of saving a friend’s life? His parents had more righteousness in their little fingers than these prattling and pretentious fools — where was their repentance? The self-righteous religious cast him out of the Temple, and the long journey home was silent, and awkward, and hopeless.

The crowds were immense, if the stories be true — this charlatan must have some slick magic up his sleeve, and there was no shortage of gullible fools in the world to follow along. His angry protests were to no avail — must he go through this humiliation once again? — as the Four lifted him onto the cart and began the dusty and agonizing ride to ridicule. Not even close — they could barely see the house for the mob. The Four muscled their way through the grumbling crowd, and ignoring the shouting owner, climbing a fig tree by the house. Before he could protest yet again, they lifted him onto the roof, nearly dropping him in the process — what a fitting and ironic end to his pathetic life that would be! Now what? They began to claw at the straw and tiles; curses arose from below as mud and straw and shards of clay tumbled onto upturned faces. Then they lowered him into the darkness.

He saw their eyes first: seated above the crowd, dressed in fine linen robes, their phylacteries glittering with fiery jewels, their eyes blazing with hatred and contempt seemingly from the very depths of Sheol. Then, turning, he saw at last the healer’s eyes: strong, kind, penetrating to the depths of his spirit. To see them was to gaze into eternity, and see its joy. He felt utterly naked — but not ashamed.

He smiled: “Son, your sins are forgiven.”

There was no challenge this time — he knew the sins of which the healer spoke: bitterness, unforgiveness, cynicism, ingratitude, the hatred of God, of life, the despair over lost promise and shattered hopes. There befell then a lightness, an extraordinary peace, the lifting of a burden far heavier than that his friends had borne in bringing him here. A smile crossed his face, for the first time in many years: could this be joy?

Amazed at his inner awakening, he failed to hear the gasps, to notice the stunned silence of the once-noisy crowd. There was only the angry, strident whispers, hushed at first, then ever more intense, like the growl of a ravenous predator: Blasphemy. Blasphemy! BLASPHEMY!

He looked back at the healer: there was no fear, no anger; naught but an enormous strength, his eyes afire with the conviction of truth. “That you may know that the Son of Man has the power on earth to forgive sins…” He looked directly into his eyes: “Arise, pick up your mat, and walk.” It was far more invitation than command.

It lasted but an instant, but seemed an eternity. Great warmth seared through his withered flesh. Tendons tight as iron loosened and stretched; his shriveled muscles softened and fleshed out; his papyrus-thin skin pinked and plumped into a vibrant glow. He sat up — before realizing he could not do so. Swinging his legs free, he stood — he stood!! — bent over, and rolled up his mat.

The crowd gasped, and cried, and praised God; he heard none of it, not even the joyful shouts of his friends on the roof. As he bounded out the door, every hand reached out to touch him, as if he, the healed, had the power of the healer. As the sounds of the crowds faded into the distance, he touched his newborn limbs, still stunned in disbelief about what had just happened.

There was much work to do; relationships to repair, amends to make, and the endless telling of his story to the amazement of all who would listen. He followed the Master throughout Galilee wherever he preached. Sitting among the thousands, he nevertheless saw Jesus look directly at him each time, and smile. It seemed as though the Master had even more joy at the healing of his crippled heart than he himself did — and his own was indescribable.

Many months after his healing, he wandered again into the desert, alone. The storm clouds were gathering: the hatred he had seen in the eyes of the religious leaders was ever more intense, and he sensed something dark and foreboding ahead in his Master’s mission. His own journey led him back to the cliffs, where his life had changed forever. His eyes gazed upward at their great height, then slowly descended to the rocks of brokenness below. He recalled his Master’s words, spoken so prophetically: “Greater love than this no man has, than to lay down his life for his friends.”

And finally, at long last, he understood.

Check it out:

Tempest Milky Way from Randy Halverson on Vimeo.

And this, with the winter sky in time lapse photography:

Sub Zero – winter night timelapse from Randy Halverson on Vimeo.

As individuals and small groups, physicians have proved to be an independent lot — “herding cats” a common metaphor for getting the profession to toe the line, even on matters beneficial to them. Once they have been herded under one roof, however, the job of controlling and coercing them becomes far easier.

Ever hear the term “ACO”? No? Better get familiar with it, because this is your future.

Accountable Care Organizations are the government’s new carrot & stick to control costs and micromanage the health care profession and industry. Those of you who’ve been around a while may remember HMOs — the insurance industry’s innovation in the late 80′s to get control of spiraling health care costs. Using a mechanism called capitation, the HMO would pay a lump sum to physicians and groups to manage “patient lives.” The theory — which worked, unfortunately — was to flip the incentives: rather than “reward” physicians for providing medical services and ordering tests and procedures, remunerate them instead for doing less: the less care provided, the more money the physicians got to keep.

Can you say, “moral hazard”, boys and girls?

It worked–all too well. Primary care physicians became “gatekeepers” whose job it was to make sure no “unnecessary” care was given. Need to see a specialist? No can do. CT scan? Unnecessary, don’t you know. Every time the doctor said “no”, their wallet got a bit fatter. It cut costs dramatically when introduced. Of course, patients got sicker; cancers took longer to diagnose and treat; needed diagnostic and necessary but expensive treatments were deferred or not done at all. While some unnecessary and redundant care did get eliminated, the overall effect was disastrous. Since the HMO’s bore significant financial risks, it became a fine art to “manage” those risks, to wit: you had to make sure that the “patient lives” you contractually managed were not very sick, lest you break the bank taking care of medical disasters, poorly-compliant patients (typically the poor), and the elderly. The system imploded when patients revolted, followed shortly thereafter by politicians (who had been prime movers behind the HMO juggernaut) demonizing the monster they themselves had created. No worries: they now had a new straw man to attack, the “evil insurance companies” of their own design; this ogre lives on to this day.

They say that insanity is repeatedly doing the same thing, while expecting different results each time: enter ACOs.

So what are ACOs?

Like most bad ideas, the concept originated in the think tanks of academia, where “health care experts” who never take care of patients dream up idyllic solutions to problems they don’t understand. ACOs are defined as follows:

ACOs can generally be defined as a local entity and a related set of providers, including at least primary care physicians, specialists, and hospitals, that can be held accountable for the cost and quality of care delivered to a defined subset of traditional Medicare program beneficiaries or other defined populations, such as commercial health plan subscribers. The primary ways the entity would be held accountable for its performance are through changes in traditional Medicare provider payment featuring financial rewards for good performance based on comprehensive quality and spending measurement and monitoring. Public reporting of cost and quality information to affect public perception of an ACO’s worth is another way of holding the ACO accountable for its performance.

ACOs have three main characteristics:

1. The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care;
2. The capability of prospectively planning budgets and resource needs;
3. Sufficient size to support comprehensive, valid, and reliable performance measurement.

In English, for those fortunate souls unschooled in the lingo of academic health care policy , this means a health care organization, comprised of hospitals (with their associated services, such as radiology, operating rooms, inpatient beds, physical therapy, etc., etc.), doctors and other health professionals (e.g., PAs and nurse practitioners), all centrally managed with an eye toward controlling costs and those who generate those costs (see “providers”, above), large enough to generate meaningful statistics on costs and health care “outcomes”, reportable back to Medicare and Big Insurance for their “review.”

The benefits to providers of aligning with such a cumbersome, micromanaged, top-heavy beast? You got it: the lure of filthy lucre:

In exchange for investing in this reformed health care provider structure, the ACO members will share in the savings that results from their cooperation and coordination. Thus, ACOs can–theoretically–act as a reform tool by incentivizing more efficient and effective care. This would help to combat the current perverse incentives of overutilization and overbuilding of health care facilities and technology.

So what could possibly go wrong with this model?

[The ACO model] was built on what is (to my consulting colleagues, anyway) a stunningly obvious discovery: Medicare spending for physician services tends to cluster around hospital service areas.

The policy leap that led to the ACO idea was that since these “communities” already use hospitals, let’s assume that they and their hospitals are actually “virtual organizations” and give them a global budget. Consumers would not be aware that they were being treated by ACOs. Rather, they would be “attributed” to them: virtual patients of virtual organizations. Aggregate health spending for attributed patients would be tracked, and increases in that spending would be capped using a form of “shadow capitation.” ACOs that lived within the caps would get their fees increased. Those that overspent would see their fees reduced or frozen.

Some policy types on the Medicare Payment Advisory Commission (MedPAC) became intrigued with the ACO idea and saw it as a solution to the Sustainable Growth Rate (SGR) problem, a durable policy headache bequeathed by Congress to physicians in the Balanced Budget Act

The SGR cuts payments to physicians when health care costs rise, nominally maintaing “budget neutrality”, and has been routinely overridden by Congress because of real concerns over restricting access to medicare patients.

If a national SGR didn’t work to constrain physician behavior, why not create a hospital service area–specific SGR?

Fisher and colleagues theorize that when you cap the total resources coming into a specific “community,” hospitals and physicians would form organizations to accept and manage the global payments. This would create an economically motivated community lobby for not building more hospital beds, not recruiting additional cardiologists, not putting CT scanners in physician offices. Little delegations from the ACO would visit the high utilizers and work with them to get them to give up their diagnostic equipment and reduce their incomes. (As Dave Barry would say, “I am not making this up.”)

The problem with this movie is that we’ve actually seen it before, and it was a colossal and expensive failure. During the 1990s, many hospitals and physicians believed that the Clinton health reforms would force them into capitated contracts with health plans. This catalyzed a flurry of mergers and physician practice acquisitions, all motivated by a desire to control the stream of payments from health plans, rather than being subcontractors to those who did. Many system builders assumed that they would increase their market share through selective contracting at the expense of docs and hospitals that remained unorganized.

Risk-bearing physician/hospital organizations and hospital-sponsored preferred provider organizations (PPOs) sprang up all over the country. They typically paid their docs a discounted fee based on prevailing rates in the community … in anticipation of capitated health plan payments. Some of these hospital/physician efforts actually succeeded …

However, these were outliers in an expensive failure. Employers and patients preferred open panels managed by health insurers to closed panels managed by providers. Billions of dollars were lost. After rivers of red ink, most bold 1990s hospital risk-sharing experiments were terminated, along with the CEOs and physician leaders who created them. Many of the practice acquisitions were reversed, as hospital systems sought to rein in their expenses and adjust to an open-panel world dominated by point-of-service style health plans.

Why did they fail?

The State of Massachusetts seems headed toward imposing an all-payer mandatory, communitywide ACO model for cost containment purposes. There is time to reconsider what I think is a reckless decision. … the Massachusetts ACO experiment is likely to be a gory and comprehensive failure. Virtual assignment of patients, virtual organizations, “shadow capitation” superimposed on fee-for-service based economically independent docs, further consolidation of local hospital monopolies: we really ought to know better….

The sad reality is that most hospitals, even the well-managed ones, simply lack the tools, leadership, and leverage to enable them to bear and manage global risk. Many will not possess them in a decade. The mandatory ACO (apparently still a live option in the June 2009 MedPAC report) is one of the worst health system reform ideas since the Health Systems Agency. Fisher and his colleagues are attempting to broaden the idea to encompass independent practice associations (IPAs), existing multispecialty groups, even academic health centers. But the core idea remains that physician communities and hospitals in defined geographies are viable economic units. They are not.

The elephant in the room — never addressed in this grand schema to control costs — is the medical liability monster. Huge amounts of medical services and costs are driven by defensive medicine. ACOs will provide no protection to their physicians as they drive down costs by haranguing them while denying services, diagnostic tests, and procedures based on cost, thinly disguised as “quality.” Every physician hears the voice of an attorney when he decides to order a medical test, which may be of marginal benefit to the patient: “Doctor, didn’t you realize that by ordering a CT scan, Mrs. Jones’ cancer could have been diagnosed earlier, and cured?” The defense that “My ACO told me it was unnecessary and expensive” will be no defense at all: “And when you refused to order that scan, Doctor, you stood to make more money, didn’t you?” Devastating–and inevitable.

But the bottom line is that medical decision-making will become further removed from the patient and his physician, decisions now moved to faceless bureaucrats with Excel spreadsheets and no medical degree. Once again, the “experts” will win — and you will lose.

Be afraid — be very afraid.