The unintended consequences of the establishment of "Accountable care organizations" on geriatric care and independent providers:
- "Accountable care organizations" get incentive payments for following, CMS established, quality indicators. The rub is that the quality indicators used as a measure of good care are not always applicable to geriatric patients. For example, the standard of putting all stroke patients on a statin (i.e. Lipitor) doesn't necessarily apply to frail elderly over 80, 90, over even 100 years old, and yet in order to keep the quality indicators on target and get CMS bonus money, many hospitals who are part of ACOs are encouraging the application of these standards across the board, regardless of age or frailty. The hospital employed physicians are often given bonuses for meeting quality indicator targets, which adds another incentive to continue this robotic centralized decision making approach.
This point can be further illustrated by the fact that when the statins are stopped by geriatricians or PCPs post discharge from the hospital, the patients gets re-started on the statin upon their next hospital admission, as if nothing else matters except the hospital protocols to meet the quality indicator targets.
Other examples include diabetic patients goals; in geriatric cases the A1c goal is 8 for many nursing home patients, and hypoglycemia is considered a bigger threat to the elderly's well-being than uncontrolled diabetes. These emerging standards in geriatric care are not reflected in the quality indicators used in the general population, and geriatricians can be potentially penalized for doing the right thing while ACOs are financially rewarded for doing the wrong thing (one that happens to be good on paper and is based on CMS standards).
Why is CMS responsible for this?
. By incentivizing the establishment of Accountable Care Organizations, CMS is effectively pushing the health care industry to centralize care and decision making and eliminate the independent provider models as a choice of practice. It's is also promoting centralized rigid treatment protocols, that are based primarily on clinical goals linked to financial interests, and geared towards meeting targets that qualify corporate providers and institutions for bonus payments from CMS. These rigid quality indicator targets are based on information that is constantly evolving, making the system highly communistic in it's design.
. Pay for performance, based on rigid quality measures, is inherently problematic, as government standards are not likely to evolve with the evolution of science, and as ACOs take hold, employed providers would be unduly influenced to practice cookie-cutter centralized care, even when it eventually becomes outdated.
. As CMS pushes for establishment of ACO through financial incentives, it is actually undermining free market principles in healthcare and diminishes the role of physicians in developing a "patient centered" care plan. ACOs are also creating a conflict of interest for physicians as they practically now receive commission for following protocols at bedside.
An example of such care trends based on quality indicators is most obvious in palliative care or hospice patients. There are many hospice patients on comfort measures that leave the hospital on statins for having a history of hypercholestrolemia, or for their recent stroke or heart attack. In such cases the hospitalists are clearly documenting that prolonging life is no longer the goal, and yet they leave these patients on life prolonging medications, that if discontinued, would impact the quality indicators statistics for their institution, and in some cases impact the doctors' own bonuses.
And so we end up with a 90 year old patient on comfort measures being kept on Lipitor to make sure the ACOs stays on target in terms of quality indicators, and the doctors don't put up a fight because their bonuses depend on it.
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