For as long as anyone can remember, U.S. health care has used a pretty simple model: If you didn't feel well, you went to your doctor. If you were acutely ill or injured, you went to the hospital.
With numerous pilot programs in the Affordable Care Act (ACA) tweaking that paradigm, the country may see some progress on reducing medical costs, which are among the highest in the industrialized world.
Academics admit that they may be stymied by one huge barrier: habits. Millions may be using emergency rooms even when they don't need to go. They may avoid doctors in the early stages of a disease, making further treatment more expensive. Or they may feel that long hospital stays are the "best way to get better."
In an effort to improve care while cutting costs, the ACA has endorsed a number of ways to create "patient-centered" care that employs a team approach to treatment. "Accountable Care Organizations" and "medical homes" are part of this new strategy.
The reasoning behind this coordinated care, which has long been in use by the Cleveland and Mayo Clinics, is to focus on the patient's needs, ideally in one setting with a team of providers who are all on the same page.
Medical homes, for example, evolved in the late 1960s as ways to become a "one-stop shop" for acute, chronic, mental and wellness care. All care is coordinated by one team.
While the coordinated approach strives to improve care by paring unnecessary tests and procedures, it may not save much money or boost health outcomes. A recent large study of medical homes by the Journal of the American Medical Association found that there was "no cost savings and only a modest improvement in quality."
Although study of coordinated care is still in its infancy, it begs another question: Will institutional change be enough? Won't you have to change patient habits to lower costs?
The Next Step: Behavioral Change
American patients may be spoiled due to the "buffet effect." Because most middle to upper class Americans have so many health care choices, they avail themselves of everything they can.
Don't like your local hospital? You can find a major research hospital that will specialize in the kind of care you are seeking in another city. Not satisfied with local specialists? You can search the country. Not crazy about the drugs you're getting? You can ask for the latest and newest pill, just as so many pharmaceutical ads implore you to do.
Although many of the most-advanced treatments are paid for directly by patients, the fee-for-service system covers any number of options — and that could lead to overspending. Patients may also seek treatments that are not available locally. But it will take further research to show how — and if — patients are spending excessively on care that ultimately proves ineffective or superfluous. That's one of the many questions asked through pilot studies in the ACA.
Congress will also find out whether groups such as Medicare Accountable Care Organizations (ACOs), which focus on concentrating resources and lowering costs, are actually effective in pooling care to cut costs. It could well be that patients may eschew them for older care models, where they can choose from a smorgasbord of providers and treatments.
For now, the panoply of choice doesn't bode well for cost reduction. In the future, it's possible that the best economic incentives (i.e., lower premiums, out-of-pocket costs) will be paired with the best-possible treatments, drugs and procedures. Until then, patients will go to any lengths to find the care they perceive offers the most favorable outcomes.
That may be why patient-focused health care groups that limit the number of providers may not ultimately reduce spending — at least initially. For this evidence, you may want to take a look at how patients are regarding the launch of ACOs.
A recent study by Harvard researchers suggests that patients may not like having restricted choice in providers. The researchers found that the patients they analyzed sought doctors outside their ACOs for two-thirds of their visits to specialists.
Part of the problem may also be that the sickest patients not only seek the greatest amount of care, they may not be getting the targeted attention they need in a "one size fits all" system. They could be lost in a maze of hospitals and clinics that shuffle them from one facility to another. The current system is set up to bill for every procedure and test, but may not identify what the highest-risk patients actually need.
“ACOs are having difficulty coordinating care because they don't know who their patients are and, if patients see providers outside of your network, it's hard to control cost and quality,” Chet Speed, vice president of public policy with the American Medical Group Association, told Modern Healthcare. “The problem with ACOs is that you have care-management requirements overlaid on a very imperfect fee-for-service system.”
If Congress is to tackle the cost/quality curve in health care, it needs to change the institutional habits of providers, then give incentives to patients to seek the right kind of care that's focused on making them well — and keeping them healthy.
Tough questions need to be answered by academic research. What treatments, drugs or surgeries prove to be ineffective? How do you wean patients from asking for care that won't ultimately help them? Behavioral changes will ultimately come from greater education and patient communication, two of the weakest suits of the current system.
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