Will the Affordable Care Act overwhelm the Health System?

In the midst of the fury, anger, and frustration with the Affordable Care Act we have been focused on chronic care, outcomes, meaningful use, accountable care organizations, HIT, and coming changes in reimbursement paradigms.

The increasing rates of obesity, hypertension, diabetes mellitus, breast cancer. colon cancer sits in stark opposition to acute illnesses, such as flu, otitis media, pharyngitis, bronchitis, pneumonia, infectious gastroenteritis,  and the tsunami of routine care, skin rashes, exanthems, pregnancy and it's secondary consequences as well.

Raising the bar for excellence in chronic disease management as measured by somewhat subjective criteria does not occur in isolation. This will have an effect on the system's ability to deal with the 'walking ill".   The overwhelming majority of health care takes place in an outpatient environment.  Monitoring this segment will require extensive monitoring and a means to encourage clinicians to use evidence based medicine. EBM at

it's best can be questionable and subject to clinical judgment and years of experience. Given the recent experience with screening for prostate cancer and breast cancer imaging standards were reversed after controversy erupted, and the USPHS did a quick reversal of it's stand on prevention of breast cancer and prostate cancer.

While the majority of health costs occur in the population above 55 years of age, this portion of the population is not as active in the economy.  Younger patients illnesses effect their attendance and ability to participate in the workforce, at times.  This is a  'hidden expense; to the system which is difficult to measure.

The initial phases of the Affordable Care Act have caused employers to look carefully at their full-time work force, and will shift to more part-time employment.  This will in turn stimulate the Individual Family  Plans not tied to an employer group plan.  History reveals these IFPs are more expensive to administrate than GHPs.

It has been a more than decade long crusade to develop a plan such as the ACA. Some are ecstatic and even euphoric about the ACA to the point of an unrealistic assessment of what the ACA can accomplish.  The very worthwhile plan  has caused a deep divide between fiscal conservatives, and liberals. What we need is more 'reaching across the aisle and open minds.  Both sides must lower the volume.

ACO Expectations may be Unrealistic

According to a survery of  115 Hospital C-Level executives reveal that about 18% are participating in accountable care organization activities.  This figure is increased from 5% % in 2012.   Half of respondents expect to be in an ACO by the end of 2014.

Whether that lofty figure can be reached remains to be seen. Provider alliance Premier Inc. conducted the new survey in August but only recently released results. The spring 2012 survey found that nearly 52 percent of respondents expected to be in the ACO arena by the end of 2013. Now, Premier estimates only 23.5 percent will reach that goal.

A further analysis of hosptial size revealed: 

Non-rural hospitals are most likely to participate in an ACO, followed by hospitals in integrated delivery systems; and rural hospitals are least likely to participate, followed by standalone facilities.

Large hospitals are moving more quickly toward ACOs than smaller ones, although the majority of surveyed hospitals are making infrastructure investments to manage population health.

This may be effected by the availability of capital resources which are often lacking in smaller institutions, and a much smaller group of medical providers and/or a lack of specialty access.

These investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

The efforts include a wide variety of investments to increase utiilization of the ACO as a public health resource. 

* The investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

* Fifty-one percent of responding hospitals are partnering with large local employers to improve care.

* Large numbers of respondents are gearing up for analytics to support population health. More than 72 percent are integrating claims and clinical data, half are using predictive analytics to forecast needs and 46 percent are using a data warehouse to reduce information silos.

* More than 40 percent are partnering with insurers, particularly for upside-only shared savings programs.

The programs require strategic rethinking of hospital scope of care.  The effort will require integration of previously unlinked services in preventive medicine, and health, wellness and nutrition.

The full report from Premiere Inc can be found here.

Holiday Message for Health and Wellness

Today my message is one of hope and optimism. Health and Wellness are dear to us all.

We have many tools, HIT, EMRs, ACOs, ACA, Health Benefit Exchanges and more to come. Who knows what is next or what we have built, or predict will be here in five years.  Chances are very good, they will not be based upon our looking back ten years.  Not much is left from those days.

My message today is about 'shifting sands'

Much of what you and I read or write about health care, health information technology should be taken with a grain of salt.  It is all written from the narrow confines of our own experience(s)

It all goes beyond my capability to absorb and synthesize.


Much of what I seek is answered by the parables.  My hope is that all will take away some glint of wisdom from these words, no matter what the challenge.

Building on a Solid Foundation

24“Anyone who listens to my teaching and follows it is wise, like a person who builds a house on solid rock. 25Though the rain comes in torrents and the floodwaters rise and the winds beat against that house, it won’t collapse because it is built on bedrock. 26But anyone who hears my teaching and doesn’t obey it is foolish, like a person who builds a house on sand. 27When the rains and floods come and the winds beat against that house, it will collapse with a mighty crash.”

The Tree and Its Fruit

15“Beware of false prophets who come disguised as harmless sheep but are really vicious wolves. 16You can identify them by their fruit, that is, by the way they act. Can you pick grapes from thornbushes, or figs from thistles? 17A good tree produces good fruit, and a bad tree produces bad fruit. 18A good tree can’t produce bad fruit, and a bad tree can’t produce good fruit. 19So every tree that does not produce good fruit is chopped down and thrown into the fire. 20Yes, just as you can identify a tree by its fruit, so you can identify people by their actions.

Effective Prayer

7“Keep on asking, and you will receive what you ask for. Keep on seeking, and you will find. Keep on knocking, and the door will be opened to you. 8For everyone who asks, receives. Everyone who seeks, finds. And to everyone who knocks, the door will be opened.

This is my holiday gift to all.

Gary Levin M.D.