'OneCare' approach not the right answer for health care

January 11, 2018

Addison Independent

By G. Richard Dundas MD

I happened to see your article regarding our Vermont Accountable Care Organization called OneCare (Addison Independent, Jan. 4). It painted a rosy picture of how OneCare will save us all: improve our care, keep us healthy, and reduce our costs mainly by changing how providers and hospitals are paid. My bet is that OneCare will fail us.

First, the method of paying providers and hospitals is not the primary problem. The primary problem is that there are multiple insurers, most of which are motivated by profit and who think of health care as a commodity to be sold. A single payer as proposed by Sen. Sanders would reduce administrative overhead and lower the cost of care.

Second, the ability to control the high cost of pharmaceuticals is a high priority that can only be addressed with a single payer authorized to negotiate with Big Pharma.

Third, most doctors are already motivated to improve their care, but our health care system does not allow them to do so. Rather, they have to worry about such things as documenting their care so that the insurance company will honor their efforts with a payment. Or they might spend their time arguing with the insurance company clerk to get a CT scan preapproved. There is a difference between being motivated and having enough time and energy to implement a new system. Many doctors in Vermont may know little about new care models that will be required, and there might be a long learning curve.

Fourth, not all doctors are treated the same. Primary care doctors will be paid a “capitated” amount (they will receive a certain payment per enrolled patient, whether or not the patient receives any services). Specialists however will still be paid fee-for-service. We all know how expensive specialist care can be. Think about all the testing that the specialist might wish to order.

Fifth, the primary care doctor will “have a foot in two canoes.” Some of his patients will be enrolled in OneCare, but others will not. Coping with two patient populations will be difficult to manage and might require two models of care.

Sixth, the primary care physician is not receiving much help from OneCare. We all know that population health outcomes are largely dependent on the social determinants of health, not on the care that the patient receives from the provider or hospital. Social determinants of health are such things as income, employment, education, housing, transportation and nutrition. If you have all of these things plus healthy personal habits, you are much more likely to live longer and better. OneCare is not providing enough financial aid so that the doctor could hire an additional case manager or social service support person to address the patient’s social problems.

Seventh, OneCare’s financial incentives (a share in the savings for OneCare patients) are probably too weak to change provider behavior in a meaningful way. And that assumes that there will be savings — OneCare has had a budgetary deficit in the past three years (no savings were earned).

Eighth, the burden of change falls mainly on the primary care provider. This species is already endangered. Be kind to your PCP.

I could go on, but my computer is starting to smoke.

G. Richard Dundas, MD, Bennington