“It’s Hard Work, but It’s Good for the Soul”: Accountable Care in the Trenches

From Brigham and Women’s Hospital, Boston, MA.

I have always grazed on the medical commons [1]. My practice style was “accountable” years before I even knew what that meant. It wasn’t a conscious choice. It certainly wasn’t a statement about how the school district where my mom worked couldn’t afford to hire new teachers because of the rising cost of health care. When I finished medical training in 1991, I was more worried about killing a patient than about the patient losing health insurance if they left their job to start a business, let alone the downstream effects of that on the US economy.

I’ve just always had a value practice style. I never liked hospitals. I’m proud of my control issues, and there were just too many people, too much chaos, and too many opportunities for a medical error in the hospital. And it always seemed to me that most patients would rather feel lousy in their own bed, with a home-cooked meal and their family near, than in a hospital surrounded by strangers eating lousy food on an uncomfortable mattress (remember, I’m talking the 90s).

But my value bent is not just pro-home and anti-hospital. It’s my personal aesthetic of care. I enjoy the intellectual challenge of figuring out the right test to use to answer the question fastest with the least inconvenience for the patient. There is nothing quite like hitting upon the exact right medication regimen for a depressed alcoholic hypertensive diabetic patient with COPD and gout. And oh the joy when the patient calls and says their abdominal pain resolved on its own, meaning your plan to use watchful waiting rather than order an expensive abdominal CT of uncertain benefit saved the patient from unnecessary harm. Volume-driven care is a temptation to lazy thinking. Why would I want to do that?

I’ve been practicing for 23 years. I spent the bulk of my career practicing in what was arguably, in its time, the best Medicare ACO in the country—before anyone had invented the idea of an ACO [2]. I also led its department of general internal medicine in 2004 when the clinic decided to dis-integrate and de-capitate—transition from single-payer capitation to multipayer fee-for-service (oops!). In 2008, trying to understand why no medical students wanted to do what I love doing (being a general internist), I moved to an academic medical system and found myself back in the heart of fee-for-service medicine. And now, completing the circle, that same academic medical system is in the process of trying to move from volume to value, signing up to become a Medicare Pioneer ACO as well as entering into the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract [3].

So how does it feel to practice in the trenches of an accountable care organization? Honestly, I’m not sure. First I’ll write what I do know: what it feels like to practice in a fee-for-service organization, and what it feels like to practice in a capitated organization.

Fee-for-service tempts one to do too much; capitation tempts one to do too little. The most ethical reimbursement proposal I’ve ever heard was that half of my patients would be fee-for-service and half capitated, and I wouldn’t find out which ones were which until the next year. No one would agree to write or sign that contract, but you can’t ignore its appeal.

Stylistically, I prefer capitation. I like the flexibility to think “outside the exam room” and do the right thing for the patient without having to worry about whether there is a relative value unit (RVU) tied to it. But value-based care is hard. The incentive in fee-for-service medicine is to see 2 healthy patients with sore throats and send the decompensating patient with multiple complex medical and psychosocial problems to the emergency room. The incentive in capitation is to add the complex patient on to the end of the schedule. In fee-for-service care, the metrics you are judged on are visits and RVUs. Nice and concrete—and something you can control. In capitation, the metrics are number of patients cared for and how much their care costs—a lot harder to measure, a lot more responsibility, and a lot less control since in the end it is the patient who takes the medication, gets the test done, sees the consultant, and changes their lifestyle. Or not.

I have never been particularly enamored of practicing in a pure fee-for-service system. Admittedly, I have only practiced in the CPT/RVU version of the fee-for-service system that has existed since the 1990s. An awfully weird version of fee-for-service if you ask me, since it only pays for one thing—me in a room with a patient. Not on the phone, not e-mailing, not video chatting. Not talking to their family, even if it’s in person. Not talking to the hospitalist, or ED doc, or their cardiologist.

Even weirder, it pays me a lot more for doing (procedures and tests) than for talking and thinking. And it refuses to pay many of the nonphysician clinicians I’ve worked with over the years for doing the same work, even if they can do it better than I can for less.

Continuing down the strangeness path, even if the system valued talking and thinking as much as I do, that’s not really what it pays me for. Instead, it pays me for documenting from a Chinese menu of CPT codes (one from column A, two from column B). Do I do 3 History of Present Illness (HPI) elements or 4? Did my Review of Systems contain 9 systems or 10? How many body systems did I examine? Why is it that a 99214 requires only 3 stable chronic diseases to max out my diagnostic/management options when it feels like most patients I see have so many more? Don’t I deserve a bonus for each additional one? And, not to hurt the feelings of whomever created this system, it takes a lot more time and energy to explain to the patient about false positives and the danger of doing an MRI for new-onset back pain than to just fill out the form and order it. Do they have any idea how long it takes to explain to a patient why antibiotics don’t cure viral infections? Yet I receive more medical decision-making points for ordering than not ordering the MRI or antibiotic. Really???

And, weirdest of all, they pay me whether or not I help the patient feel better or live a longer, healthier life. They even pay me for fixing my own complications.

As probably every parent in the world has told every child in the world, you get what you pay for. Nothing I’ve described above is actually paying me for the heart of what I do as a PCP—providing accessible, comprehensive, coordinated and continuous (person-focused care over time) care. Yes, at least for my generation, relationships are built, one-on-one in the exam room with the patient. But relationships require quality time together (ask your spouse), something that is hard to do when you are seeing patients every 15 minutes, and half that time is spent tapping away at a keyboard to meet CPT requirements (not to mention Meaningful Use and Joint Commission and every other regulatory body who wants a piece of my time with the patient).

In theory, it would be easy to construct a fee-for-service system that pays for many of the things I’ve mentioned above. I could be much more accessible if you paid me for email and video chats, plus a little extra to cover the cost of keeping the office open late on weekdays and opening on weekends. I could be much more comprehensive if you paid me to provide all the care the patient needed during a visit, not just what they came in for, and to build and work a registry to provide care between visits. I could be much more coordinated if you paid me (or the nurse or social worker I team with) to check in on patients and to communicate with the specialists and other clinicians my patients are seeing. Changing the reimbursement scheme so that I can focus on seeing only the patients who really need to be seen in person by a doctor, and paying enough for that visit so we can have the time together we need, would go a long way to building those all-important continuous relationships.

And some payers are trying to do this. Hence, new CPT codes from Medicare to report transitional care management (TCM) services for patients, and Blue Cross Blue Shield of Michigan making itself a nice return on investment and simultaneously improving quality of care by creating fee-for-service reimbursements that pay for only a small portion of the activities I mentioned above [4].

So when I say I prefer capitation to fee-for-service, what I’m really saying is I dislike the usual fee-for-service system, but I liked the capitation of the physician-led organization that was committed to value-based care and meeting the needs of the community it served [2]. Not the capitation I experienced in the first year and a half of my career, where there were no adjustments for patient complexity, no balancing quality measures, and no idea how to care manage a patient—a system where certain practices “won” by subtly pushing sick patients to seek care elsewhere.

Which brings me back to: How does it feel to practice in the trenches of an accountable care organization? Or specifically, what does it feel like to practice in an academic medical system 2 years into its transition into becoming an ACO?

In 2011, when ACOs were first appearing, they were compared to unicorns: everyone knows what they look like, but no one has actually seen one. Three years on, that seems a bit unfair. I suspect the current analogy should be that ACOs are like werewolves: they behave like fee-for-service organizations day-to-day, but at some mysterious reconciliation moment in the future, they magically turn into capitated organizations. As best as I can figure out, no full moon is involved.

What do I mean? I am lucky enough to spend 5/8 of my time practicing and 1/8 of my time leading a primary care innovation site for my employer—think Patient-Centered Medical Home on steroids. We’ve made it clear to everyone on the team that we are a Triple Aim–driven practice, and that our job is to keep people healthy, and by keeping them healthy we keep them out of the emergency department and the hospital. By being proactive, coordinating care, having same-day phone, email, and in-person access, staying open until 7 pm and opening on Saturday, booking on a 20-minute schedule, and by aggressively addressing our patients’ psychosocial issues on top of their medical issues, this hardy band of doctors, physician assistants, nurses, medical assistants, administrative assistants, social workers, pharmacist, nutritionist, and community health worker have spent our 3 years together improving population health, providing a great patient experience, and preventing more than enough unnecessary ED visits and hospital admissions to cover the cost of the team many times over. I look forward to going to work in the morning, and leave at night tired but satisfied.

One of our assumptions in designing the practice was that reimbursements would shift from volume to value. When we interviewed pharmacists and nutritionists, we were very clear that if they didn’t create value and if reimbursement didn’t change, we could not guarantee their jobs beyond 2 years. We were surprised, but also breathed a sigh of relief, when 4 months after we opened the organization signed the accountable care agreements. We wouldn’t be too far ahead of reimbursement reform, and if we just executed our vision we would easily financially justify our existence.

Oops. The organization was still being paid fee-for-service in real time. The monthly budget was still fee-for-service. That reconciliation of actual vs. expected cost of care was a theoretical event somewhere off in the future that no one knew how to divvy up. The cost of the extra team members was a current expense in the budget not matched by any revenue. We spent a lot of time explaining a very large variance.

Furthermore, a key financial metric for the organization is percentage of hospital beds occupied, while the practice is hoping to use percentage decrease in ambulatory-sensitive admissions as a metric of our economic success. It feels like a potential conflict, though thankfully this has never become a concern like the budget variance.

And by the way, 80% of our doctors’ clinical salary is still based on RVUs. And we’ve built a perfect system to minimize the docs’ RVUs. Easy visits are done by phone and email, slightly harder visits by the PAs. Visits to manage patients with 1 or 2 chronic diseases the pharmacist and nurses do. Doctors work at the top of their licenses, seeing patients with 5 to 10 problems who don’t fit into any protocol. But that top of the license still usually codes as a 99214. There are no RVUs for working with the team. So the need to generate RVUs (and the revenue that comes with them) remains a major constraint on the practice’s imagination.

Thankfully, there are many people in the organization who recognize our value beyond the revenue line in our budget. The team allows physicians to carry a much larger panel, so we talk about new patients to the system and downstream revenue to those who still think of us as a fee-for-service organization. For those who still live by the percent occupancy metric, we point out that the hospital is still full, and the medical admissions we tend to prevent wouldn't be nearly as profitable as the elective procedures that fill the beds instead. We take complex patients who are running amok through the system and bring them under control, allowing specialists to concentrate on what they do best. We take patients who can’t be discharged safely from the emergency room and inpatient floors because they lack the functioning primary care relationship needed for follow-up and see them within 3 days. And, to their credit, many people can think beyond this year’s budget, and even beyond the ACO reconciliation next year, to our mission of caring for populations.

And maybe, just maybe, that is why accountable care organizations will succeed. Because the people who run our ACO know our practice cares for a culturally diverse inner-city population where obesity and diabetes are huge problems. And they’ve seen our data that the nutritionist-pharmacist team is significantly lowering A1cs. So despite the budget variance they create, the organization keeps paying their salaries. Maybe because the mission of the organization includes meeting the medical needs of the community we serve. Maybe because those lower A1cs earn us quality bonuses. Maybe because those newly in-control diabetic patients make fewer visits to the ED and have fewer costly complications. I’m not sure it even matters why. What matters is they understand my practice and its population in a way that someone in Washington never will and never can.

Imagine if the practice was independent, and I wanted Medicare to pay my docs for working with the team and for all the phone and email care they provide. I wouldn’t even know where to start and, honestly, there is no chance it would happen. Of course, it hasn’t happened yet in the ACO I’m in. But at least in our ACO I know which human being to talk to, and that human being is also a doctor, and he knows my practice and the patients it serves. Yes, he’s my boss, and yes, he has bosses of his own, but at least we are having a dialogue about the possibility of tying less compensation to RVUs.

I tend to be skeptical. It’s a good internist skill. You don’t really want a doc who says, “I just saw it on Oprah, let’s give it a try.” I remain skeptical that ACOs will succeed. But if they do, it will be because they push the decisions about how to allocate resources much closer to the trenches.

Do I have concerns about the ACO in which I live? Plenty. I’ve already mentioned 3: the fact that we continue to budget like we are a fee-for-service organization, the need to “feed the beast” and keep the hospital full, and the disconnect between the system being paid for value while the doctors continue to be paid for volume. To be fair to the naysayers, most of our revenue still comes from fee-for-service reimbursement, with a small but rising percentage coming from ACO contracts. It’s hard to stand in 2 canoes. We have this huge, expensive FFS infrastructure—hospital beds, MRI machines, cath labs, etc. There is a leap of faith involved in hiring the people (RN care coordinators, nutritionists, pharmacists, social workers, and community health workers) who make up the “infrastructure” of an ACO. What if we don’t bend cost trend and having paid all these salaries also have to pay a penalty after we already decreased our day-to-day fee-for-service revenue? Even in the best case, it’s not like systems learn to provide value-based care overnight. So you are hiring the RN care managers now, but it could be years before you see a big enough drop off in visits to shelve the plans to expand the ED.

And all this involves eventually shifting resources from the ED to primary care, from inpatient to outpatient. No department is going to volunteer to do this. Even no-brainers, such as building systems that increase necessary fee-for-service revenue-generating care (screening mammograms and colonoscopies, for example) can create food fights. The most effective outreach to get patients in for these tests comes from the patient’s primary care team. But it takes time, and time is money. And after primary care spends that money, the revenue accrues to radiology and gastroenterology. How do you deal with that? And if you can’t deal with that, how do you divvy up any future bonus the system gets from splitting savings in total cost of care with the insurers?

I have this strong impression that the organization is trying as hard as possible to transform itself with an absolute commitment to not upsetting the very difficult  to recruit and retain specialists who fill the beds with all those high-paying elective procedures. If encouraging them to provide care in a less expensive setting within the ACO gets them upset, why risk finding out what happens when we ask them to fundamentally change how they spend their day, who they work with, and how they interact with patients?

But from my point of view in the trenches, it seems to me that we can’t really achieve accountable care until my day as a doctor, and the day of every nurse, pharmacist, social worker, administrative assistant, medical assistant, and administrator, feels fundamentally different than it did in a volume-based system. Patients make changes when it takes less energy to make the change than to maintain the status quo. Organizations aren’t any different. Primary care usually goes first in moving toward accountable care because the status quo is so dysfunctional. But primary care is only a fraction of the cost of care in the United States. The status quo for specialists, especially those procedural specialists, is pretty darned good. How many of them will make the leap, and how many will resist?

Society is entitled to some say in what it gets for its money. Meaning we, primary care and specialists alike, need to take responsibility for the societal benefits that the high cost of health care is forcing out: the new teacher not hired, the new business not started.

I don’t like change any more than any other doctor. Nor am I fully convinced that accountable care organizations are the right solution to the problems with fee-for-service medicine. But I do know that as doctors we have spent our careers making some pretty big sacrifices for our patients. Maybe I’m naive, but I do believe that most of us will agree to make massive changes in our day-to-day lives. But only after we’re convinced that those changes are the right thing for our patients and society, and hence the right thing for us.

Of course, I don’t need convincing; it’s the way I’ve always practiced. How many visits I’m going to do that day is not what gets me out of bed in the morning. I don’t want my lifetime RVU total on my gravestone. I went to medical school to help people, not to accumulate widgets of care.

So, where to start? I was talking with one of the younger docs in our practice a few weeks ago, asking how things were going. His response is the best argument I’ve ever heard for justifying transformation in the trenches from volume to value: “It’s hard work, but it’s good for the soul.”

Corresponding author: Stuart M. Pollack, MD, 301 S. Huntington Ave., Jamaica Plain, MA 02130, [email protected]

Financial disclosures: None.

From Brigham and Women’s Hospital, Boston, MA.

I have always grazed on the medical commons [1]. My practice style was “accountable” years before I even knew what that meant. It wasn’t a conscious choice. It certainly wasn’t a statement about how the school district where my mom worked couldn’t afford to hire new teachers because of the rising cost of health care. When I finished medical training in 1991, I was more worried about killing a patient than about the patient losing health insurance if they left their job to start a business, let alone the downstream effects of that on the US economy.

I’ve just always had a value practice style. I never liked hospitals. I’m proud of my control issues, and there were just too many people, too much chaos, and too many opportunities for a medical error in the hospital. And it always seemed to me that most patients would rather feel lousy in their own bed, with a home-cooked meal and their family near, than in a hospital surrounded by strangers eating lousy food on an uncomfortable mattress (remember, I’m talking the 90s).

But my value bent is not just pro-home and anti-hospital. It’s my personal aesthetic of care. I enjoy the intellectual challenge of figuring out the right test to use to answer the question fastest with the least inconvenience for the patient. There is nothing quite like hitting upon the exact right medication regimen for a depressed alcoholic hypertensive diabetic patient with COPD and gout. And oh the joy when the patient calls and says their abdominal pain resolved on its own, meaning your plan to use watchful waiting rather than order an expensive abdominal CT of uncertain benefit saved the patient from unnecessary harm. Volume-driven care is a temptation to lazy thinking. Why would I want to do that?

I’ve been practicing for 23 years. I spent the bulk of my career practicing in what was arguably, in its time, the best Medicare ACO in the country—before anyone had invented the idea of an ACO [2]. I also led its department of general internal medicine in 2004 when the clinic decided to dis-integrate and de-capitate—transition from single-payer capitation to multipayer fee-for-service (oops!). In 2008, trying to understand why no medical students wanted to do what I love doing (being a general internist), I moved to an academic medical system and found myself back in the heart of fee-for-service medicine. And now, completing the circle, that same academic medical system is in the process of trying to move from volume to value, signing up to become a Medicare Pioneer ACO as well as entering into the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract [3].

So how does it feel to practice in the trenches of an accountable care organization? Honestly, I’m not sure. First I’ll write what I do know: what it feels like to practice in a fee-for-service organization, and what it feels like to practice in a capitated organization.

Fee-for-service tempts one to do too much; capitation tempts one to do too little. The most ethical reimbursement proposal I’ve ever heard was that half of my patients would be fee-for-service and half capitated, and I wouldn’t find out which ones were which until the next year. No one would agree to write or sign that contract, but you can’t ignore its appeal.

Stylistically, I prefer capitation. I like the flexibility to think “outside the exam room” and do the right thing for the patient without having to worry about whether there is a relative value unit (RVU) tied to it. But value-based care is hard. The incentive in fee-for-service medicine is to see 2 healthy patients with sore throats and send the decompensating patient with multiple complex medical and psychosocial problems to the emergency room. The incentive in capitation is to add the complex patient on to the end of the schedule. In fee-for-service care, the metrics you are judged on are visits and RVUs. Nice and concrete—and something you can control. In capitation, the metrics are number of patients cared for and how much their care costs—a lot harder to measure, a lot more responsibility, and a lot less control since in the end it is the patient who takes the medication, gets the test done, sees the consultant, and changes their lifestyle. Or not.

I have never been particularly enamored of practicing in a pure fee-for-service system. Admittedly, I have only practiced in the CPT/RVU version of the fee-for-service system that has existed since the 1990s. An awfully weird version of fee-for-service if you ask me, since it only pays for one thing—me in a room with a patient. Not on the phone, not e-mailing, not video chatting. Not talking to their family, even if it’s in person. Not talking to the hospitalist, or ED doc, or their cardiologist.

Even weirder, it pays me a lot more for doing (procedures and tests) than for talking and thinking. And it refuses to pay many of the nonphysician clinicians I’ve worked with over the years for doing the same work, even if they can do it better than I can for less.

Continuing down the strangeness path, even if the system valued talking and thinking as much as I do, that’s not really what it pays me for. Instead, it pays me for documenting from a Chinese menu of CPT codes (one from column A, two from column B). Do I do 3 History of Present Illness (HPI) elements or 4? Did my Review of Systems contain 9 systems or 10? How many body systems did I examine? Why is it that a 99214 requires only 3 stable chronic diseases to max out my diagnostic/management options when it feels like most patients I see have so many more? Don’t I deserve a bonus for each additional one? And, not to hurt the feelings of whomever created this system, it takes a lot more time and energy to explain to the patient about false positives and the danger of doing an MRI for new-onset back pain than to just fill out the form and order it. Do they have any idea how long it takes to explain to a patient why antibiotics don’t cure viral infections? Yet I receive more medical decision-making points for ordering than not ordering the MRI or antibiotic. Really???

And, weirdest of all, they pay me whether or not I help the patient feel better or live a longer, healthier life. They even pay me for fixing my own complications.

As probably every parent in the world has told every child in the world, you get what you pay for. Nothing I’ve described above is actually paying me for the heart of what I do as a PCP—providing accessible, comprehensive, coordinated and continuous (person-focused care over time) care. Yes, at least for my generation, relationships are built, one-on-one in the exam room with the patient. But relationships require quality time together (ask your spouse), something that is hard to do when you are seeing patients every 15 minutes, and half that time is spent tapping away at a keyboard to meet CPT requirements (not to mention Meaningful Use and Joint Commission and every other regulatory body who wants a piece of my time with the patient).

In theory, it would be easy to construct a fee-for-service system that pays for many of the things I’ve mentioned above. I could be much more accessible if you paid me for email and video chats, plus a little extra to cover the cost of keeping the office open late on weekdays and opening on weekends. I could be much more comprehensive if you paid me to provide all the care the patient needed during a visit, not just what they came in for, and to build and work a registry to provide care between visits. I could be much more coordinated if you paid me (or the nurse or social worker I team with) to check in on patients and to communicate with the specialists and other clinicians my patients are seeing. Changing the reimbursement scheme so that I can focus on seeing only the patients who really need to be seen in person by a doctor, and paying enough for that visit so we can have the time together we need, would go a long way to building those all-important continuous relationships.

And some payers are trying to do this. Hence, new CPT codes from Medicare to report transitional care management (TCM) services for patients, and Blue Cross Blue Shield of Michigan making itself a nice return on investment and simultaneously improving quality of care by creating fee-for-service reimbursements that pay for only a small portion of the activities I mentioned above [4].

So when I say I prefer capitation to fee-for-service, what I’m really saying is I dislike the usual fee-for-service system, but I liked the capitation of the physician-led organization that was committed to value-based care and meeting the needs of the community it served [2]. Not the capitation I experienced in the first year and a half of my career, where there were no adjustments for patient complexity, no balancing quality measures, and no idea how to care manage a patient—a system where certain practices “won” by subtly pushing sick patients to seek care elsewhere.

Which brings me back to: How does it feel to practice in the trenches of an accountable care organization? Or specifically, what does it feel like to practice in an academic medical system 2 years into its transition into becoming an ACO?

In 2011, when ACOs were first appearing, they were compared to unicorns: everyone knows what they look like, but no one has actually seen one. Three years on, that seems a bit unfair. I suspect the current analogy should be that ACOs are like werewolves: they behave like fee-for-service organizations day-to-day, but at some mysterious reconciliation moment in the future, they magically turn into capitated organizations. As best as I can figure out, no full moon is involved.

What do I mean? I am lucky enough to spend 5/8 of my time practicing and 1/8 of my time leading a primary care innovation site for my employer—think Patient-Centered Medical Home on steroids. We’ve made it clear to everyone on the team that we are a Triple Aim–driven practice, and that our job is to keep people healthy, and by keeping them healthy we keep them out of the emergency department and the hospital. By being proactive, coordinating care, having same-day phone, email, and in-person access, staying open until 7 pm and opening on Saturday, booking on a 20-minute schedule, and by aggressively addressing our patients’ psychosocial issues on top of their medical issues, this hardy band of doctors, physician assistants, nurses, medical assistants, administrative assistants, social workers, pharmacist, nutritionist, and community health worker have spent our 3 years together improving population health, providing a great patient experience, and preventing more than enough unnecessary ED visits and hospital admissions to cover the cost of the team many times over. I look forward to going to work in the morning, and leave at night tired but satisfied.

One of our assumptions in designing the practice was that reimbursements would shift from volume to value. When we interviewed pharmacists and nutritionists, we were very clear that if they didn’t create value and if reimbursement didn’t change, we could not guarantee their jobs beyond 2 years. We were surprised, but also breathed a sigh of relief, when 4 months after we opened the organization signed the accountable care agreements. We wouldn’t be too far ahead of reimbursement reform, and if we just executed our vision we would easily financially justify our existence.

Oops. The organization was still being paid fee-for-service in real time. The monthly budget was still fee-for-service. That reconciliation of actual vs. expected cost of care was a theoretical event somewhere off in the future that no one knew how to divvy up. The cost of the extra team members was a current expense in the budget not matched by any revenue. We spent a lot of time explaining a very large variance.

Furthermore, a key financial metric for the organization is percentage of hospital beds occupied, while the practice is hoping to use percentage decrease in ambulatory-sensitive admissions as a metric of our economic success. It feels like a potential conflict, though thankfully this has never become a concern like the budget variance.

And by the way, 80% of our doctors’ clinical salary is still based on RVUs. And we’ve built a perfect system to minimize the docs’ RVUs. Easy visits are done by phone and email, slightly harder visits by the PAs. Visits to manage patients with 1 or 2 chronic diseases the pharmacist and nurses do. Doctors work at the top of their licenses, seeing patients with 5 to 10 problems who don’t fit into any protocol. But that top of the license still usually codes as a 99214. There are no RVUs for working with the team. So the need to generate RVUs (and the revenue that comes with them) remains a major constraint on the practice’s imagination.

Thankfully, there are many people in the organization who recognize our value beyond the revenue line in our budget. The team allows physicians to carry a much larger panel, so we talk about new patients to the system and downstream revenue to those who still think of us as a fee-for-service organization. For those who still live by the percent occupancy metric, we point out that the hospital is still full, and the medical admissions we tend to prevent wouldn't be nearly as profitable as the elective procedures that fill the beds instead. We take complex patients who are running amok through the system and bring them under control, allowing specialists to concentrate on what they do best. We take patients who can’t be discharged safely from the emergency room and inpatient floors because they lack the functioning primary care relationship needed for follow-up and see them within 3 days. And, to their credit, many people can think beyond this year’s budget, and even beyond the ACO reconciliation next year, to our mission of caring for populations.

And maybe, just maybe, that is why accountable care organizations will succeed. Because the people who run our ACO know our practice cares for a culturally diverse inner-city population where obesity and diabetes are huge problems. And they’ve seen our data that the nutritionist-pharmacist team is significantly lowering A1cs. So despite the budget variance they create, the organization keeps paying their salaries. Maybe because the mission of the organization includes meeting the medical needs of the community we serve. Maybe because those lower A1cs earn us quality bonuses. Maybe because those newly in-control diabetic patients make fewer visits to the ED and have fewer costly complications. I’m not sure it even matters why. What matters is they understand my practice and its population in a way that someone in Washington never will and never can.

Imagine if the practice was independent, and I wanted Medicare to pay my docs for working with the team and for all the phone and email care they provide. I wouldn’t even know where to start and, honestly, there is no chance it would happen. Of course, it hasn’t happened yet in the ACO I’m in. But at least in our ACO I know which human being to talk to, and that human being is also a doctor, and he knows my practice and the patients it serves. Yes, he’s my boss, and yes, he has bosses of his own, but at least we are having a dialogue about the possibility of tying less compensation to RVUs.

I tend to be skeptical. It’s a good internist skill. You don’t really want a doc who says, “I just saw it on Oprah, let’s give it a try.” I remain skeptical that ACOs will succeed. But if they do, it will be because they push the decisions about how to allocate resources much closer to the trenches.

Do I have concerns about the ACO in which I live? Plenty. I’ve already mentioned 3: the fact that we continue to budget like we are a fee-for-service organization, the need to “feed the beast” and keep the hospital full, and the disconnect between the system being paid for value while the doctors continue to be paid for volume. To be fair to the naysayers, most of our revenue still comes from fee-for-service reimbursement, with a small but rising percentage coming from ACO contracts. It’s hard to stand in 2 canoes. We have this huge, expensive FFS infrastructure—hospital beds, MRI machines, cath labs, etc. There is a leap of faith involved in hiring the people (RN care coordinators, nutritionists, pharmacists, social workers, and community health workers) who make up the “infrastructure” of an ACO. What if we don’t bend cost trend and having paid all these salaries also have to pay a penalty after we already decreased our day-to-day fee-for-service revenue? Even in the best case, it’s not like systems learn to provide value-based care overnight. So you are hiring the RN care managers now, but it could be years before you see a big enough drop off in visits to shelve the plans to expand the ED.

And all this involves eventually shifting resources from the ED to primary care, from inpatient to outpatient. No department is going to volunteer to do this. Even no-brainers, such as building systems that increase necessary fee-for-service revenue-generating care (screening mammograms and colonoscopies, for example) can create food fights. The most effective outreach to get patients in for these tests comes from the patient’s primary care team. But it takes time, and time is money. And after primary care spends that money, the revenue accrues to radiology and gastroenterology. How do you deal with that? And if you can’t deal with that, how do you divvy up any future bonus the system gets from splitting savings in total cost of care with the insurers?

I have this strong impression that the organization is trying as hard as possible to transform itself with an absolute commitment to not upsetting the very difficult  to recruit and retain specialists who fill the beds with all those high-paying elective procedures. If encouraging them to provide care in a less expensive setting within the ACO gets them upset, why risk finding out what happens when we ask them to fundamentally change how they spend their day, who they work with, and how they interact with patients?

But from my point of view in the trenches, it seems to me that we can’t really achieve accountable care until my day as a doctor, and the day of every nurse, pharmacist, social worker, administrative assistant, medical assistant, and administrator, feels fundamentally different than it did in a volume-based system. Patients make changes when it takes less energy to make the change than to maintain the status quo. Organizations aren’t any different. Primary care usually goes first in moving toward accountable care because the status quo is so dysfunctional. But primary care is only a fraction of the cost of care in the United States. The status quo for specialists, especially those procedural specialists, is pretty darned good. How many of them will make the leap, and how many will resist?

Society is entitled to some say in what it gets for its money. Meaning we, primary care and specialists alike, need to take responsibility for the societal benefits that the high cost of health care is forcing out: the new teacher not hired, the new business not started.

I don’t like change any more than any other doctor. Nor am I fully convinced that accountable care organizations are the right solution to the problems with fee-for-service medicine. But I do know that as doctors we have spent our careers making some pretty big sacrifices for our patients. Maybe I’m naive, but I do believe that most of us will agree to make massive changes in our day-to-day lives. But only after we’re convinced that those changes are the right thing for our patients and society, and hence the right thing for us.

Of course, I don’t need convincing; it’s the way I’ve always practiced. How many visits I’m going to do that day is not what gets me out of bed in the morning. I don’t want my lifetime RVU total on my gravestone. I went to medical school to help people, not to accumulate widgets of care.

So, where to start? I was talking with one of the younger docs in our practice a few weeks ago, asking how things were going. His response is the best argument I’ve ever heard for justifying transformation in the trenches from volume to value: “It’s hard work, but it’s good for the soul.”

Corresponding author: Stuart M. Pollack, MD, 301 S. Huntington Ave., Jamaica Plain, MA 02130, [email protected]

Financial disclosures: None.

From Brigham and Women’s Hospital, Boston, MA.

I have always grazed on the medical commons [1]. My practice style was “accountable” years before I even knew what that meant. It wasn’t a conscious choice. It certainly wasn’t a statement about how the school district where my mom worked couldn’t afford to hire new teachers because of the rising cost of health care. When I finished medical training in 1991, I was more worried about killing a patient than about the patient losing health insurance if they left their job to start a business, let alone the downstream effects of that on the US economy.

I’ve just always had a value practice style. I never liked hospitals. I’m proud of my control issues, and there were just too many people, too much chaos, and too many opportunities for a medical error in the hospital. And it always seemed to me that most patients would rather feel lousy in their own bed, with a home-cooked meal and their family near, than in a hospital surrounded by strangers eating lousy food on an uncomfortable mattress (remember, I’m talking the 90s).

But my value bent is not just pro-home and anti-hospital. It’s my personal aesthetic of care. I enjoy the intellectual challenge of figuring out the right test to use to answer the question fastest with the least inconvenience for the patient. There is nothing quite like hitting upon the exact right medication regimen for a depressed alcoholic hypertensive diabetic patient with COPD and gout. And oh the joy when the patient calls and says their abdominal pain resolved on its own, meaning your plan to use watchful waiting rather than order an expensive abdominal CT of uncertain benefit saved the patient from unnecessary harm. Volume-driven care is a temptation to lazy thinking. Why would I want to do that?

I’ve been practicing for 23 years. I spent the bulk of my career practicing in what was arguably, in its time, the best Medicare ACO in the country—before anyone had invented the idea of an ACO [2]. I also led its department of general internal medicine in 2004 when the clinic decided to dis-integrate and de-capitate—transition from single-payer capitation to multipayer fee-for-service (oops!). In 2008, trying to understand why no medical students wanted to do what I love doing (being a general internist), I moved to an academic medical system and found myself back in the heart of fee-for-service medicine. And now, completing the circle, that same academic medical system is in the process of trying to move from volume to value, signing up to become a Medicare Pioneer ACO as well as entering into the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract [3].

So how does it feel to practice in the trenches of an accountable care organization? Honestly, I’m not sure. First I’ll write what I do know: what it feels like to practice in a fee-for-service organization, and what it feels like to practice in a capitated organization.

Fee-for-service tempts one to do too much; capitation tempts one to do too little. The most ethical reimbursement proposal I’ve ever heard was that half of my patients would be fee-for-service and half capitated, and I wouldn’t find out which ones were which until the next year. No one would agree to write or sign that contract, but you can’t ignore its appeal.

Stylistically, I prefer capitation. I like the flexibility to think “outside the exam room” and do the right thing for the patient without having to worry about whether there is a relative value unit (RVU) tied to it. But value-based care is hard. The incentive in fee-for-service medicine is to see 2 healthy patients with sore throats and send the decompensating patient with multiple complex medical and psychosocial problems to the emergency room. The incentive in capitation is to add the complex patient on to the end of the schedule. In fee-for-service care, the metrics you are judged on are visits and RVUs. Nice and concrete—and something you can control. In capitation, the metrics are number of patients cared for and how much their care costs—a lot harder to measure, a lot more responsibility, and a lot less control since in the end it is the patient who takes the medication, gets the test done, sees the consultant, and changes their lifestyle. Or not.

I have never been particularly enamored of practicing in a pure fee-for-service system. Admittedly, I have only practiced in the CPT/RVU version of the fee-for-service system that has existed since the 1990s. An awfully weird version of fee-for-service if you ask me, since it only pays for one thing—me in a room with a patient. Not on the phone, not e-mailing, not video chatting. Not talking to their family, even if it’s in person. Not talking to the hospitalist, or ED doc, or their cardiologist.

Even weirder, it pays me a lot more for doing (procedures and tests) than for talking and thinking. And it refuses to pay many of the nonphysician clinicians I’ve worked with over the years for doing the same work, even if they can do it better than I can for less.

Continuing down the strangeness path, even if the system valued talking and thinking as much as I do, that’s not really what it pays me for. Instead, it pays me for documenting from a Chinese menu of CPT codes (one from column A, two from column B). Do I do 3 History of Present Illness (HPI) elements or 4? Did my Review of Systems contain 9 systems or 10? How many body systems did I examine? Why is it that a 99214 requires only 3 stable chronic diseases to max out my diagnostic/management options when it feels like most patients I see have so many more? Don’t I deserve a bonus for each additional one? And, not to hurt the feelings of whomever created this system, it takes a lot more time and energy to explain to the patient about false positives and the danger of doing an MRI for new-onset back pain than to just fill out the form and order it. Do they have any idea how long it takes to explain to a patient why antibiotics don’t cure viral infections? Yet I receive more medical decision-making points for ordering than not ordering the MRI or antibiotic. Really???

And, weirdest of all, they pay me whether or not I help the patient feel better or live a longer, healthier life. They even pay me for fixing my own complications.

As probably every parent in the world has told every child in the world, you get what you pay for. Nothing I’ve described above is actually paying me for the heart of what I do as a PCP—providing accessible, comprehensive, coordinated and continuous (person-focused care over time) care. Yes, at least for my generation, relationships are built, one-on-one in the exam room with the patient. But relationships require quality time together (ask your spouse), something that is hard to do when you are seeing patients every 15 minutes, and half that time is spent tapping away at a keyboard to meet CPT requirements (not to mention Meaningful Use and Joint Commission and every other regulatory body who wants a piece of my time with the patient).

In theory, it would be easy to construct a fee-for-service system that pays for many of the things I’ve mentioned above. I could be much more accessible if you paid me for email and video chats, plus a little extra to cover the cost of keeping the office open late on weekdays and opening on weekends. I could be much more comprehensive if you paid me to provide all the care the patient needed during a visit, not just what they came in for, and to build and work a registry to provide care between visits. I could be much more coordinated if you paid me (or the nurse or social worker I team with) to check in on patients and to communicate with the specialists and other clinicians my patients are seeing. Changing the reimbursement scheme so that I can focus on seeing only the patients who really need to be seen in person by a doctor, and paying enough for that visit so we can have the time together we need, would go a long way to building those all-important continuous relationships.

And some payers are trying to do this. Hence, new CPT codes from Medicare to report transitional care management (TCM) services for patients, and Blue Cross Blue Shield of Michigan making itself a nice return on investment and simultaneously improving quality of care by creating fee-for-service reimbursements that pay for only a small portion of the activities I mentioned above [4].

So when I say I prefer capitation to fee-for-service, what I’m really saying is I dislike the usual fee-for-service system, but I liked the capitation of the physician-led organization that was committed to value-based care and meeting the needs of the community it served [2]. Not the capitation I experienced in the first year and a half of my career, where there were no adjustments for patient complexity, no balancing quality measures, and no idea how to care manage a patient—a system where certain practices “won” by subtly pushing sick patients to seek care elsewhere.

Which brings me back to: How does it feel to practice in the trenches of an accountable care organization? Or specifically, what does it feel like to practice in an academic medical system 2 years into its transition into becoming an ACO?

In 2011, when ACOs were first appearing, they were compared to unicorns: everyone knows what they look like, but no one has actually seen one. Three years on, that seems a bit unfair. I suspect the current analogy should be that ACOs are like werewolves: they behave like fee-for-service organizations day-to-day, but at some mysterious reconciliation moment in the future, they magically turn into capitated organizations. As best as I can figure out, no full moon is involved.

What do I mean? I am lucky enough to spend 5/8 of my time practicing and 1/8 of my time leading a primary care innovation site for my employer—think Patient-Centered Medical Home on steroids. We’ve made it clear to everyone on the team that we are a Triple Aim–driven practice, and that our job is to keep people healthy, and by keeping them healthy we keep them out of the emergency department and the hospital. By being proactive, coordinating care, having same-day phone, email, and in-person access, staying open until 7 pm and opening on Saturday, booking on a 20-minute schedule, and by aggressively addressing our patients’ psychosocial issues on top of their medical issues, this hardy band of doctors, physician assistants, nurses, medical assistants, administrative assistants, social workers, pharmacist, nutritionist, and community health worker have spent our 3 years together improving population health, providing a great patient experience, and preventing more than enough unnecessary ED visits and hospital admissions to cover the cost of the team many times over. I look forward to going to work in the morning, and leave at night tired but satisfied.

One of our assumptions in designing the practice was that reimbursements would shift from volume to value. When we interviewed pharmacists and nutritionists, we were very clear that if they didn’t create value and if reimbursement didn’t change, we could not guarantee their jobs beyond 2 years. We were surprised, but also breathed a sigh of relief, when 4 months after we opened the organization signed the accountable care agreements. We wouldn’t be too far ahead of reimbursement reform, and if we just executed our vision we would easily financially justify our existence.

Oops. The organization was still being paid fee-for-service in real time. The monthly budget was still fee-for-service. That reconciliation of actual vs. expected cost of care was a theoretical event somewhere off in the future that no one knew how to divvy up. The cost of the extra team members was a current expense in the budget not matched by any revenue. We spent a lot of time explaining a very large variance.

Furthermore, a key financial metric for the organization is percentage of hospital beds occupied, while the practice is hoping to use percentage decrease in ambulatory-sensitive admissions as a metric of our economic success. It feels like a potential conflict, though thankfully this has never become a concern like the budget variance.

And by the way, 80% of our doctors’ clinical salary is still based on RVUs. And we’ve built a perfect system to minimize the docs’ RVUs. Easy visits are done by phone and email, slightly harder visits by the PAs. Visits to manage patients with 1 or 2 chronic diseases the pharmacist and nurses do. Doctors work at the top of their licenses, seeing patients with 5 to 10 problems who don’t fit into any protocol. But that top of the license still usually codes as a 99214. There are no RVUs for working with the team. So the need to generate RVUs (and the revenue that comes with them) remains a major constraint on the practice’s imagination.

Thankfully, there are many people in the organization who recognize our value beyond the revenue line in our budget. The team allows physicians to carry a much larger panel, so we talk about new patients to the system and downstream revenue to those who still think of us as a fee-for-service organization. For those who still live by the percent occupancy metric, we point out that the hospital is still full, and the medical admissions we tend to prevent wouldn't be nearly as profitable as the elective procedures that fill the beds instead. We take complex patients who are running amok through the system and bring them under control, allowing specialists to concentrate on what they do best. We take patients who can’t be discharged safely from the emergency room and inpatient floors because they lack the functioning primary care relationship needed for follow-up and see them within 3 days. And, to their credit, many people can think beyond this year’s budget, and even beyond the ACO reconciliation next year, to our mission of caring for populations.

And maybe, just maybe, that is why accountable care organizations will succeed. Because the people who run our ACO know our practice cares for a culturally diverse inner-city population where obesity and diabetes are huge problems. And they’ve seen our data that the nutritionist-pharmacist team is significantly lowering A1cs. So despite the budget variance they create, the organization keeps paying their salaries. Maybe because the mission of the organization includes meeting the medical needs of the community we serve. Maybe because those lower A1cs earn us quality bonuses. Maybe because those newly in-control diabetic patients make fewer visits to the ED and have fewer costly complications. I’m not sure it even matters why. What matters is they understand my practice and its population in a way that someone in Washington never will and never can.

Imagine if the practice was independent, and I wanted Medicare to pay my docs for working with the team and for all the phone and email care they provide. I wouldn’t even know where to start and, honestly, there is no chance it would happen. Of course, it hasn’t happened yet in the ACO I’m in. But at least in our ACO I know which human being to talk to, and that human being is also a doctor, and he knows my practice and the patients it serves. Yes, he’s my boss, and yes, he has bosses of his own, but at least we are having a dialogue about the possibility of tying less compensation to RVUs.

I tend to be skeptical. It’s a good internist skill. You don’t really want a doc who says, “I just saw it on Oprah, let’s give it a try.” I remain skeptical that ACOs will succeed. But if they do, it will be because they push the decisions about how to allocate resources much closer to the trenches.

Do I have concerns about the ACO in which I live? Plenty. I’ve already mentioned 3: the fact that we continue to budget like we are a fee-for-service organization, the need to “feed the beast” and keep the hospital full, and the disconnect between the system being paid for value while the doctors continue to be paid for volume. To be fair to the naysayers, most of our revenue still comes from fee-for-service reimbursement, with a small but rising percentage coming from ACO contracts. It’s hard to stand in 2 canoes. We have this huge, expensive FFS infrastructure—hospital beds, MRI machines, cath labs, etc. There is a leap of faith involved in hiring the people (RN care coordinators, nutritionists, pharmacists, social workers, and community health workers) who make up the “infrastructure” of an ACO. What if we don’t bend cost trend and having paid all these salaries also have to pay a penalty after we already decreased our day-to-day fee-for-service revenue? Even in the best case, it’s not like systems learn to provide value-based care overnight. So you are hiring the RN care managers now, but it could be years before you see a big enough drop off in visits to shelve the plans to expand the ED.

And all this involves eventually shifting resources from the ED to primary care, from inpatient to outpatient. No department is going to volunteer to do this. Even no-brainers, such as building systems that increase necessary fee-for-service revenue-generating care (screening mammograms and colonoscopies, for example) can create food fights. The most effective outreach to get patients in for these tests comes from the patient’s primary care team. But it takes time, and time is money. And after primary care spends that money, the revenue accrues to radiology and gastroenterology. How do you deal with that? And if you can’t deal with that, how do you divvy up any future bonus the system gets from splitting savings in total cost of care with the insurers?

I have this strong impression that the organization is trying as hard as possible to transform itself with an absolute commitment to not upsetting the very difficult  to recruit and retain specialists who fill the beds with all those high-paying elective procedures. If encouraging them to provide care in a less expensive setting within the ACO gets them upset, why risk finding out what happens when we ask them to fundamentally change how they spend their day, who they work with, and how they interact with patients?

But from my point of view in the trenches, it seems to me that we can’t really achieve accountable care until my day as a doctor, and the day of every nurse, pharmacist, social worker, administrative assistant, medical assistant, and administrator, feels fundamentally different than it did in a volume-based system. Patients make changes when it takes less energy to make the change than to maintain the status quo. Organizations aren’t any different. Primary care usually goes first in moving toward accountable care because the status quo is so dysfunctional. But primary care is only a fraction of the cost of care in the United States. The status quo for specialists, especially those procedural specialists, is pretty darned good. How many of them will make the leap, and how many will resist?

Society is entitled to some say in what it gets for its money. Meaning we, primary care and specialists alike, need to take responsibility for the societal benefits that the high cost of health care is forcing out: the new teacher not hired, the new business not started.

I don’t like change any more than any other doctor. Nor am I fully convinced that accountable care organizations are the right solution to the problems with fee-for-service medicine. But I do know that as doctors we have spent our careers making some pretty big sacrifices for our patients. Maybe I’m naive, but I do believe that most of us will agree to make massive changes in our day-to-day lives. But only after we’re convinced that those changes are the right thing for our patients and society, and hence the right thing for us.

Of course, I don’t need convincing; it’s the way I’ve always practiced. How many visits I’m going to do that day is not what gets me out of bed in the morning. I don’t want my lifetime RVU total on my gravestone. I went to medical school to help people, not to accumulate widgets of care.

So, where to start? I was talking with one of the younger docs in our practice a few weeks ago, asking how things were going. His response is the best argument I’ve ever heard for justifying transformation in the trenches from volume to value: “It’s hard work, but it’s good for the soul.”

Corresponding author: Stuart M. Pollack, MD, 301 S. Huntington Ave., Jamaica Plain, MA 02130, [email protected]

Financial disclosures: None.