Herzlinger Predicts ACOs, PCMHs Will Fail

Accountable care organizations and patient-centered medical homes are unlikely to succeed. Those are two predictions from Regina E. Herzlinger, a professor at the Harvard Business School who has successfully predicted some of the most powerful trends in health care since the 1990s. Arguably, most of her predictions about health care have come true or are about to.

The Nancy R. McPherson professor of business administration at the Harvard Business School, Herzlinger is the author of several widely read books on health care, including Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers (Jossey-Bass, 2004), and Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America’s Largest Service Industry (Addison-Wesley, 1997). Here’s how she assesses the current health insurance marketplace.

Feeling threatened

“Health plans are very threatened now because, if it succeeds, the movement to accountable care organizations will disintermediate them,” she says. “Many ACOs either have an insurance arm or are buying one, such as Partners Healthcare in Boston, which bought a commercial plan license.

“I hope I’m wrong about this, but I believe that with some exceptions, ACOs will not succeed,” she says. “ACOs will implode just as capitated HMOs imploded in the 1990s. People say that won’t happen because we have better data now. Wish it were true, but we don’t have better data now. The electronic medical record systems don’t talk to each other and the public health insurance exchanges are largely a dream waiting to happen, rather than a reality.

“Another reason ACOs will implode is that it will be difficult for anything but an organization that has been at it for a long time to develop the team culture needed to be an ACO,” she adds. “Kaiser Permanente can do it because it has operated that way for decades.”

In addition, Herzlinger says, ACOs will create severe antitrust problems. “If there are a lot of price increases from an oligopolistic ACO, then how could that be termed a success?” she asks. “Having said that, insurers still fear that ACOs will succeed, perhaps because they think the government will be asleep at the wheel on anti-trust. Even though, in my opinion, those fears are groundless, they still feel they must confront them. One way they are confronting those fears is by buying providers, which is not going to work. The idea that insurers can manage providers is just as unrealistic as the idea that providers can manage insurance.”

Another model of care delivery that will fail is the patient-centered medical home (PCMH), she says. “The reason PCMHs will not succeed is that health care follows the 80/20 rule — 20 percent of patients generate 80 percent of the costs,” she says. “Those 20 percent are the chronically ill, and I don’t see how primary care physicians serving these patients add value to their care. I’m a huge fan of primary care physicians and they have a vital role in making health reform succeed, but, if I were a class-three CHF patient, I would see a heart failure specialist. If I were an advanced type II diabetic, I would go to the Joslin Diabetes Center, not a primary care provider.“

Herzlinger would like to see “focused factories” of care. “That is the term I use for provider organizations that deliver highly specialized care for a certain group of patients, such as those who have diabetes, cancer, or congestive heart failure. You need specialists for that. They are the opposite of organizations, such as ACOs, that do everything for everyone.

“For all these reasons, insurers are in a hard place right now,” she continues. “One response has been to buy providers, which cannot succeed, and another response is to go abroad, which is a smart move. Insurers are developing a presence outside of the United States, helping to boost insurance competence, which is needed in developing countries. There’s a huge demand for health care around the world. China and India would be great markets for U.S. insurers. Even countries that have single-payer systems also have private insurance. Ireland, France, and Spain all have private insurance and represent opportunities for U.S. insurers.”

Risky ventures

Health insurers also face a threat from the health insurance exchanges. A variety of organizations will run the exchanges, including health insurers. “The exchanges are risky for insurers for two reasons. One, they will want to run exchanges that offer only their products, but the customer is likely to want a lot more choice. Second, in their history, they have primarily sold their products to businesses, but these exchanges demand a consumer focus. To serve consumers, health insurers will need to shift their marketing focus or leave that business to others.”

Health Plan 2020

Perspectives:

Comments

ACOs & PCMHs

Having founded and managed an MRI company meeting Dr. Herzlinger’s definition of a “focused factory”, I’m certainly aware of the benefits this approach can sometimes bring to the table. But as a model for how our healthcare system should be structured and care delivered, it would only exacerbate our current fragmentation and rampant inefficiencies.

The flaw in this academic thinking is to compartmentalize patients by their primary diagnosis. Few are the patients with type 2 diabetes who don’t also have one or more additional medical conditions in need of treatment. Continuing to treat them in diagnostic silos will only compound our current problems.

These patients don’t generally need more sophisticated high-tech interventions. Study after study documents they benefit more from low-tech, high-touch interventions best provided by primary care practices, not the Joslins of the world.

Are ACOs a panacea? Unlikely, given the critical mass they need to assume financial risk. They may well backfire by further empowering the dominant providers/insurers in each metropolitan market. PCMHs hold more promise if they can achieve the critical mass to make a difference.

But enough already with the focused factories – a theory that may have once made sense, but is a total anachronism given current system needs and priorities.This is a formula for more fragmentation, not the cross-specialty integration of care that’s the missing link in our healthcare.

Tomorrow’s entrepreneurs should be schooled in how to enhance coordination and integration of service delivery, not further compartmentalize it.

Herzlinger Predicts ACOs, PCMHs Will Fail

A funny thing happened on the way to the ACO: Insurance companies will recognize their bright future, which will not include managing the health of their insureds. ACOs will pick up the risk and insurance companies will provide the back-bone, the administrative services.

The professor also cites options for US health insurance companies including overseas ventures. Unfortunately, the US companies have a terrible track record of international experiences.

That being the case, a few have learned and now focus on traditional and limited benefit products.

Herzlinger ACO/PCMH Predictions – Yes & No

Dr. Herzlinger is probably correct in terms of the ultimate fate of ACO’s. The only entities that seem to have the resources to create these organizations are either hospitals or health plans attempting to “re-invent” themselves. The ultimate buyer of these aggregated service delivery models, employers and publicly funded programs (Medicare/Medicaid), will eventually see them for what they are – ego driven organizations looking to “control” as much of the dollar transaction as possible to help them weather the movement away from “keep ’em sick, and keep ’em comin'” – particularly hospitals. In some cases, the ACOs will actually be working quietly to slow the movement by distracting us with nothing but quality metrics versus what we’re all really looking for is measurable reductions in aggregate spending by helping all patients, including the chronically ill (the so-called 20%) receive care more efficiently – which means timely and intelligently. In terms of Dr. Herzlinger’s perspective on Patient Centered Medical Home efforts, she couldn’t be more wrong in terms of what PCMH is supposed to be versus what it might be right now for a few practices. A PCMH “capable” practice is one that can and does drive health status improvement (yes, even for the so-called 20%) and as such drives meaningful and sustainable reductions in aggregate spending. The key will be for those who ultimately pay for care, employers and publicly funded programs, is to recognize the value of these uniquely oriented primary care capabilities, invest in them and “protect” them from the cosmic forces that will seek to undermine and/or destroy them – hospitals and health plans. Hospitals don’t like the Medical Home Model of Primary Care because they will when fully realized reduce patient volumes. Health plans don’t like them because they clearly illustrate the wasted administrative dollars associated with health benefit plan, or publicly funded program administration, that would be more wisely spent at the point of care by a high performing PCMH primary care practice. The other health plan fear, which aligns them with hospitals, is that actual premium dollars will go down, which means their 15 to 20% “administrative load” will need to go down as well – fewer dollars to spread around a bloated administrative “team” that brings no value to those who ultimately pay for care – employers and publicly funded programs. I suggest Dr. Herzlinger spend a little more “research time” considering the potential of a high performing primary care practice that truly follows the Medical Home Model of Primary Care. She’ll see its more than just a label.


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