Texas Medicine Letters: April 2010

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Letters - April 2010

Tex Med. 2010;106(4):9-11.

ACOs No Long-Term Fix

The biggest concern as accountable care organizations (ACOs) roll out is that, in their current design, they are only "accountable" in the short term. (See "ACOs," February 2010 Texas Medicine , pages 20-25.)

 ACOs, in common with capitated and managed paradigms, do not reward, nor even measure, extra expense that will benefit the patient five or 10 years after the episode of care. For example, a total hip arthroplasty that is ceramic-on-ceramic may obviate a revision during the patient's lifetime. It therefore has the potential to be better for the patient and much less expensive  over his or her life. It is, however, a more expensive device measured in the short term and will therefore penalize the ACO for providing it.

Any new technology will tend to be suppressed unless it is cheaper within the episode of care for which the ACO is compensated. Measured over a patient's lifetime, the cheapest way to deliver care will always be an informed patient seeking care from a conscientious provider with adequate and up-to-date training who is not restricted artificially in his decisions on the patient's behalf. ACOs are likely to restrict those decisions, and therefore may actually increase costs.

Steve Brotherton, MD , Fort Worth

Editor's Note: Dr. Brotherton is the speaker of the TMA House of Delegates.

Medical Inflation Must Be Stopped

I can't speak to the accountable care organization (ACO) concept, but I can speak to several models that are delivering quality care at lower cost than in the rest of the nation, including Texas. Based on current reliable data, Texas is next to last in quality and second highest in cost for Medicare patients compared with all 50 states. (Louisiana is last in both.)

Intermountain Health in Salt Lake, the Cleveland Clinic, the Mayo Clinic, and several other medical organizations consistently have achieved excellence in care at significantly lower costs. Their models of care are similar but not identical. 

 Intermountain's system is being studied by The University of Texas system, including M.D. Anderson. The system is being modified to align with the needs of a different environment. These models all have salaried physicians, objective report cards on physicians and all departments of care, and complete electronic records, including the ability to measure cost and efficiency to compare results, outcomes, and various treatment models. 

 To give one example, at Intermountain, by careful data analysis and voluntary implementation of treatment, the number of elective inductions of labor before 38 weeks gestation was reduced to nil, resulting in a dramatic reduction in the census in the NICU, healthier moms and babies, and dramatic cost savings. (Western Reserve in Cleveland reports the same cost savings and quality as does Cleveland Clinic in a fee-for-service system.)

The point is we can't continue with medical inflation two times the rate of inflation. Our system is broken. Other nations control costs with price controls, a greater emphasis on primary care, and public health measures. Cost-effective care is another option, although it will be challenging to establish on a nationwide scale, to say the least. Six developed nations have no waiting lists. We have the opportunity to be the first nation to establish universal, accessible, affordable care with measurable, unsurpassed quality.

Jerry Frankel, MD,  Houston


ACOs Similar to CDOs

After reading Ken Ortolon's article on accountable care organizations (ACOs), I must conclude that ACOs are the medical equivalent of financial CDOs. Luckily, Mr. Ortolon spared us from too many acronyms, but CDOs refer to collateralized debt obligations, the repackaging of junk loans to unsuspecting optimistic investors. CDOs were a major factor in the current financial meltdown. 

 It seems that the chief goal of American financial organizations is to transfer risk to someone else. ACOs are simply a means of transferring risk to physicians. The assumption of risk is ordinarily the function of insurance companies. Doctors just want to be paid for their hard work. We don't want to get paid less if one of our patients goes back to smoking, has a myocardial infarction, and ends up with a coronary artery bypass graft that comes out of our capitated risk fund. In order to distribute such risks properly, we are encouraged to set up large groups of doctors. By the time we get enough doctors together, that just turns us into an insurance company. Anyone foolish enough to buy into this system will get crushed when the system collapses. What happened to capitalism, under which you were rewarded if you worked harder and provided excellent quality?

Kevin C. Gaffney, MD, The Woodlands

Leave Religion Out of Policy

By implying that human life begins at conception, Marc D. Pecha, MD, has injected religious dogma into what needs instead to be a rational discussion on blastocyst stem cell research. (See "No to Embryonic Stem Cell Research," February 2010 Texas Medicine, page 7.) Not everyone agrees with his view. I believe that a clump of 16 or 32 cells with no brain is not a human being. If you accept Dr. Pecha's position, we must prosecute for murder every reproductive biologist who discards a spare human blastocyst (or perhaps prosecute for genocide if a set of unneeded blastocysts is discarded).

There is a desperate need here for accuracy of terminology. The term "embryonic stem cell research" is a misnomer. A blastocyst is not an embryo. No one is proposing to carry out human embryonic stem cell research. What is in fact proposed is to study cells taken from spare human blastocysts that are otherwise slated for destruction. To advocate that we destroy spare blastocysts without using their cells for potential human benefit is an immoral stance. Were I the potential parent from whose egg or sperm such a spare blastocyst had been created, I would insist that it be used as a resource for human betterment rather than simply be left eventually to become nonviable or be discarded.

We must explain for laypeople how we can possibly consider a clump of cells that might under different circumstances have the potential to develop into a human being as being a "spare." In the process of in vitro fertilization, a greater number of blastocysts are often created than will ever be needed. More eggs are "harvested" from the mother at the time of ovulation and are fertilized in vitro than will be needed to establish a sufficient number of pregnancies. Once the couple has completed their family, the frozen blastocysts that remain will never be needed and will eventually become nonviable. These blastocysts are the ones from which cells can be harvested for study with no negative moral implications.

We do not use the term "spare" in any sense to denigrate the potential human life. We indeed hold this potential in reverence and awe. We use the term "spare" simply to indicate that there is no longer any chance that the potential for life will ever be realized for this particular blastocyst.

While I respect Dr. Pecha's right to his religion and his opinions based on that religion, I do not respect attempts to incorporate religious dogma into public policy. Foggy ethical thinking based on religious objections and incorrect terminology have held back progress in this field too long. There is never a guarantee that a new treatment or cure will develop from any one piece of biologic or medical research, but it is clear that no new cures will be found without research. It is time to move ahead.

Lawrence E. Mallette, MD, PhD, Houston

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