Connected Health: Can accountable care reverse healthcare spending trends?

BOSTON—Spending more does not equal better care. Accountable care can reverse that trend, Elliot S. Fisher, MD, MPH, said during an Oct. 25 presentation at the ninth annual Connected Health Symposium, hosted by Partners HealthCare in Boston.

Across five categories, healthcare spending is approximately 60 percent more in the highest spending regions, according to Fisher, a professor at the Geisel School of Medicine at Dartmouth, N.H. He and his colleagues wanted to know what patients were getting for that additional spending, so they examined the care Medicare beneficiaries received in those regions. What did they find out? “They don’t get more of the things we know that work according to evidence-based guidelines.”

Compared with others, Medicare beneficiaries in the highest spending regions averaged 60 percent more time in hospitals and 70 percent more time in intensive care units (ICUs) during their first year since a heart attack or initial diagnosis of colon cancer, according to Fisher. Their outcomes were no better. In addition, when asked in focus groups, providers from the highest spending regions were more likely to report poor communication, difficulty coordinating care and there was a greater perception of scarcity. “This isn’t due to patient preferences; patients don’t want to spend more time in the hospital,” Fisher said.

Accountable care initiatives, such as those occurring within the Iowa Health System in West Des Moines, that incorporate value-based purchasing or reimbursement per episode are showing signs that healthcare spending can be slowed, but Fisher suggested they the industry as a whole, and especially the public sector, could move more quickly toward an accountable care model. “Almost every private health plan is starting to experiment with medical homes and payments per episode in order to move toward the model of more accountable care,” he said. “It’s going faster in the private sector than in the public sector.”

There is a learning curve to overcome. Many discretionary decisions that providers make can be costly, but they aren’t offered best practices to make the right decisions. When do you admit a patient to the hospital? When do you put a patient in the ICU rather than a normal hospital bed? When do you order high-cost imaging? “These are the most expensive decisions we make as physicians and they’re also the decisions we’re taught nothing about in medical school,” Fisher said.

Fisher compared the healthcare spending problem to an airplane with failing engines, a bleak outlook. However, he’s confident that the trend can be reversed. “We’re all in a plane without power. We have an opportunity thanks to emerging payment models and the energy I see in this room to turn it around.”