Under the new system, the sickest patients will be viewed as the biggest burden on the ACO. Currently, the sickest 5% of U.S. patients account for 47% of medical spending, whereas the healthiest 50% of the population accounts for only 3% of health spending. Hence, individual doctors (and ACOs at large) will have a powerful incentive to include as many of the healthy 50% on their patient rolls — and as few of the sickest 5%. According to Dr. Stewart Segal, this will create a new class of patients called “ACO lepers.” As Dr. Segal bluntly warns:
Are you overweight, out of shape, or arthritic? Do you smoke, drink alcohol, or do drugs? Do you have any chronic medical problems? Are you old, have poor eyesight, losing your hearing or memory? Are you at risk of falling?
If the answer to any of these questions is yes, you are the 2011 definition of a leper. Face it, if I am accountable for how well you handle an illness, and for what your outcome is, I cannot afford to treat you unless you are highly compliant, have no other risk factors, and stand a 99% chance of getting well.
Less scrupulous providers will thus be tempted to manipulate the assignment rules to avoid these burdensome “ACO lepers.” Consulting firms are already advising prospective ACOs on the pros and cons of various patient assignment systems. Because the financial stakes are so high, some will inevitably seek to exploit these rules to their advantage, even if it’s at their patients’ expense.
Note that such gamesmanship is a problem caused by the government-imposed ACO structure. These problems don’t arise when patients control their own health spending, for instance with “direct pay” health care or with health savings accounts (HSAs). The patients decide if certain tests or procedures are worth it to them, not the government. Doctors are free to openly and honestly advise their patients on the costs and benefits of various testing and treatment options, while leaving the ultimate decision up to the patient. The incentives of doctors and patients are thus aligned, rather than pitted against one another.
Under ObamaCare, the winners will be those lobbyists, consultants, and less-scrupulous hospitals and doctors willing to “game” the system to their advantage. The losers will be those doctors unwilling to play those games — and their patients. If Americans don’t want to become sacrificial pawns to ObamaCare gamers, they must speak out before it’s too late.