General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents

By Colin P. West, MD, PhD and Denise M. Dupras, MD, PhD
JAMA, December 5, 2012
This study of a large national sample of internal medicine residents confirms that general medicine remains a less common career plan overall than subspecialty medicine. Combined with the fact that only a small minority of medical students express interest in general medicine and primary care careers, the small number of internal medicine residents reporting plans for generalist careers means a very limited number of generalists can be expected to enter practice each year.
http://jama.jamanetwork.com/article.aspx?articleid=1475191#RESULTS

This update confirms that internal medicine residents are selecting the subspecialties in preference to general medicine and primary care. In light of the pressing need for improving our primary care infrastructure, what policies should we support?
Since family medicine residents almost always eventually enter primary care, should training programs de-emphasize general internal medicine and place more emphasis on family medicine, while relegating internal medicine to the subspecialties? That would improve the allocation of residency slots since you would not be losing general medicine residents to the subspecialties after their residencies began. This is not to suggest that subspecialists should skip all training in general medicine. The purpose would be to stem the loss of generalists from the training programs.
Also many agree that the role of nurse practitioners in primary care should be expanded. This would be especially valuable in integrated health systems and medical homes. If so, the expansion should be coordinated with the family medicine programs to achieve an optimal balance of primary care professionals.
Since we aren’t getting the numbers right, shouldn’t we consider an alternative approach? If we had a federally funded national health program, wouldn’t we be striving to improve the use of our resources to be sure that our health care infrastructure is better balanced? Our current dysfunctional, fragmented method of financing our health care system doesn’t seem to be doing the job very well.

By Greg Scandlen
National Center for Policy Analysis (NCPA), December 5, 2012

Now we get to the biggest failure of them all — the individual mandate. The premise was simple: If people aren’t buying what they should (in this case, health insurance), pass a law telling them they have to, and they will. Presto, Change-o problem solved!

Now, to be fair, Congressional Democrats weren’t quite that simple minded. They threw in lots of subsidies and required that insurers enroll anyone who applied, no questions asked. So, they made it affordable and available, along with being mandated. So, it should work like a charm, right?

Well, maybe in a vacuum. But in reality this rule is being inserted into a very complex and mature system of existing subsidies, responsibilities, and incentives. In this case, one of the primary factors is the role of employers in providing and paying for coverage.

Many people, including this writer, believe that placing that responsibility on employers was a major policy screw-up that created all the wrong dynamics in health care and virtually eliminated market functions because the payer and the consumer were not the same person.

Nevertheless, it is a system we have lived with for two-thirds of a century. Almost everything about health care and employment has been built around that relationship — prospective employees consider a company’s health benefits when deciding to take a new job; employers devote a lot of staff time and resources on choosing benefit programs; laws and regulations are written to ease the problems of interruption of benefits when people change jobs; courts are concerned that employers may not always fulfill their obligations to their workers. Not all employers provide benefits, but all feel an obligation and responsibility to do so, and the ones who don’t offer health benefits often feel conflicted about it.

Unwinding all this, even if desirable, is extremely complex and should take a very long transition period as we all learn new ways of doing things.

Enter ObamaCare. This law provides stark incentives for employers to get out of the business immediately. It even assuages any guilt feelings the employer might have by, first requiring that they continue to help pay for it, and next, by offering workers richer subsidies than the employer typically can. An employer will be able to save many thousands of dollars per worker by dropping coverage and sending employees to the Obama Exchange where they will get a choice of benefits plans and substantial subsidies if they make under 400% of the poverty level. Instead of paying, say, $10,000 per worker for coverage, now the employer can pay a simple $2,000 penalty and use the savings to give each worker a raise. Most employers will be able to save even more by reducing their HR departments, and they will be freed of complaints about any problems with the health plan they offer.

In February, 2011 McKinsey & Company did a large (1,329) survey of employers asking about their intentions with the Affordable Care Act and found that 30% said their company would “probably” or “definitely” drop coverage as a result. McKinsey is an extremely credible firm, but that didn’t stop supporters of ObamaCare from lambasting the survey because it was not consistent with other economic analyses. McKinsey had to issue a statement explaining it was not intended to be an economic analysis, it was an opinion survey. I would argue that such a survey is probably far more accurate than an economic analysis that must rely too much on assumptions. Indeed, it likely understated the situation. As employers learn more about the requirements of the new law they are more likely to run away from it.

We can’t know until it happens how many employers will drop coverage, but the 30% estimated by McKinsey may be the minimum. That could mean 50 million or more people who used to get employer coverage no longer will. For those employees this means:

*  No more automatic enrollment going along with the job. People will have to take the initiative to find out about the Exchange.
*  No more pure community rating of the employee share of premiums. The Exchange will vary premiums every year based on a person’s age.
*  No more paycheck deductions of the employee share of premiums. People will have to make some kind of payment arrangement for their share of the premium.
*  No more convenient and friendly HR Department people to answer questions. People will have to seek out an “Exchange navigator” to get their questions answered.

These employees are also likely to find at the Exchange:

*  A clunky web site run by the state or federal government laying out the coverage options.
*  Overpriced insurance options. (Because insurers can no longer ask medical questions, they will have no idea what kind of risks they are enrolling, or the premiums needed to cover those risks. They will err on the side of caution and charge higher premiums.)
*  Confusion about how much they will be charged for their share of the premium. (They will be subsidized, but the amount of the subsidy will vary according to their age, income, geographic location, family size, and choice of plan.)
*  Insurance plans that cover a bunch of stuff they don’t want or need.
*  No reliable source of personalized information. (Ever tried to call the Medicare helpline?)

Finally, they will realize that they don’t need to go through all this. They can delay making a decision until they really need to get health care services:

*  Exchange coverage is guaranteed to accept them at any time with no questions asked.
*  They can save a whole lot of money by not paying premiums and using that money for more pressing needs.
*  There is no meaningful penalty for failing to enroll. What penalty there is applies only to people who make enough money to pay income taxes, and it can be collected only by seizing whatever tax return is due the taxpayer. This can be easily avoided by upping deductions at the start of the year.

Most people have very few medical expenses in the course of a year. According to this chart 50% of the people in the United States consume only 3.9% of all health care expenses each year, while the top 20% consume 78.3%. People in the top 20% will certainly want to be covered but the bottom 50% get no advantage from insurance coverage. They spend far less on services than they would on insurance premiums.

(Scandlen includes here a slide taken from a presentation on “Medicare for All” by Paul Y. Song, MD of Physicians for a National Health Program, graphically demonstrating this distribution of health care consumption.)

Obviously not everyone will make the choice to go uninsured. People who are risk-adverse, or who have ongoing medical needs, or who have small children, will continue to be covered. But every year, every person will have to decide how best to spend their money. A very large number will decide they have better things to do with that money than spend it on insurance coverage they don’t want and never use.

The odds are that after all the trauma and expense of enacting and implementing ObamaCare, we will have fewer people insured than we did before it was enacted.

http://healthblog.ncpa.org/the-crown-jewel-of-obamacare-failures-2/

Comment:

By Don McCanne, MD

Greg Scandlen is a very well informed and respected member of the policy community who has been associated with conservative/libertarian organizations such as the National Center for Policy Analysis, Cato Institute, Galen Institute and Heartland Institute. This article for NCPA is presented in its entirety to demonstrate how much agreement there is with those of us at Physicians for a
National Health Program in defining some of the problems with the highly flawed Affordable Care Act (Obamacare). This article could have been written by one of us at PNHP.

He does not offer any solutions in this particular article, though had he, it would undoubtedly be from his area of expertise and advocacy – consumer-driven health care, including health savings accounts and health reimbursement arrangements. That, of course, is quite a contrast from the single payer solution advanced by PNHP.

When there is so much agreement on what is wrong, why can’t we agree on the solution? Perhaps it’s our respective goals. We at PNHP want everyone to have affordable access to all essential health care services, as a matter of social justice. The advocates of consumer-driven health care seem to place the will of the individual consumer above that of society’s collective will for health care justice. But the divide is not quite that simple.

Supporters of an improved Medicare for all still agree that the patient (health care consumer) should make the ultimate decisions on his or her individual health care, after being informed on the options. The role of the government is to remove the financial barriers to that care.

The consumer-driven advocates would add to the health care consumer (patient) the responsibility of making spending decisions so that they would shop for higher quality and greater value. The role of the government would be to ensure access to basic health care services for those who lack the financial resources to pay for that care.

The problem with the consumer-driven approach is that is what we have now, and it isn’t working. Except for a marginal tax benefit, it doesn’t matter whether the patient’s share of cost comes from a health savings account or from other personal funds. The system perpetuates uninsurance and under-insurance which exposes far too many to financial hardship in the face of medical need.

An improved Medicare for all would eliminate financial hardship for individual patients while using public policies to reduce the excessive escalation of our collective health care spending. The latter is a task that our private insurers cannot master, but is ideally suited to a single, national, publicly-administered insurance risk pool.

Greg Scandlen understands this. He understands the inadequacies of his consumer-directed approach. I wish he could explain to us better, in terms devoid of ideology, just what is wrong with our approach – an approach that would provide everyone the care that they need in a progressively-financed system that we can all afford.

The Crown Jewel of ObamaCare Failures

By Greg Scandlen
National Center for Policy Analysis (NCPA), December 5, 2012
Now we get to the biggest failure of them all — the individual mandate. The premise was simple: If people aren’t buying what they should (in this case, health insurance), pass a law telling them they have to, and they will. Presto, Change-o problem solved!
Now, to be fair, Congressional Democrats weren’t quite that simple minded. They threw in lots of subsidies and required that insurers enroll anyone who applied, no questions asked. So, they made it affordable and available, along with being mandated. So, it should work like a charm, right?
Well, maybe in a vacuum. But in reality this rule is being inserted into a very complex and mature system of existing subsidies, responsibilities, and incentives. In this case, one of the primary factors is the role of employers in providing and paying for coverage.
Many people, including this writer, believe that placing that responsibility on employers was a major policy screw-up that created all the wrong dynamics in health care and virtually eliminated market functions because the payer and the consumer were not the same person.
Nevertheless, it is a system we have lived with for two-thirds of a century. Almost everything about health care and employment has been built around that relationship — prospective employees consider a company’s health benefits when deciding to take a new job; employers devote a lot of staff time and resources on choosing benefit programs; laws and regulations are written to ease the problems of interruption of benefits when people change jobs; courts are concerned that employers may not always fulfill their obligations to their workers. Not all employers provide benefits, but all feel an obligation and responsibility to do so, and the ones who don’t offer health benefits often feel conflicted about it.
Unwinding all this, even if desirable, is extremely complex and should take a very long transition period as we all learn new ways of doing things.
Enter ObamaCare. This law provides stark incentives for employers to get out of the business immediately. It even assuages any guilt feelings the employer might have by, first requiring that they continue to help pay for it, and next, by offering workers richer subsidies than the employer typically can. An employer will be able to save many thousands of dollars per worker by dropping coverage and sending employees to the Obama Exchange where they will get a choice of benefits plans and substantial subsidies if they make under 400% of the poverty level. Instead of paying, say, $10,000 per worker for coverage, now the employer can pay a simple $2,000 penalty and use the savings to give each worker a raise. Most employers will be able to save even more by reducing their HR departments, and they will be freed of complaints about any problems with the health plan they offer.
In February, 2011 McKinsey & Company did a large (1,329) survey of employers asking about their intentions with the Affordable Care Act and found that 30% said their company would “probably” or “definitely” drop coverage as a result. McKinsey is an extremely credible firm, but that didn’t stop supporters of ObamaCare from lambasting the survey because it was not consistent with other economic analyses. McKinsey had to issue a statement explaining it was not intended to be an economic analysis, it was an opinion survey. I would argue that such a survey is probably far more accurate than an economic analysis that must rely too much on assumptions. Indeed, it likely understated the situation. As employers learn more about the requirements of the new law they are more likely to run away from it.
We can’t know until it happens how many employers will drop coverage, but the 30% estimated by McKinsey may be the minimum. That could mean 50 million or more people who used to get employer coverage no longer will. For those employees this means:
*  No more automatic enrollment going along with the job. People will have to take the initiative to find out about the Exchange.
*  No more pure community rating of the employee share of premiums. The Exchange will vary premiums every year based on a person’s age.
*  No more paycheck deductions of the employee share of premiums. People will have to make some kind of payment arrangement for their share of the premium.
*  No more convenient and friendly HR Department people to answer questions. People will have to seek out an “Exchange navigator” to get their questions answered.
These employees are also likely to find at the Exchange:
*  A clunky web site run by the state or federal government laying out the coverage options.
*  Overpriced insurance options. (Because insurers can no longer ask medical questions, they will have no idea what kind of risks they are enrolling, or the premiums needed to cover those risks. They will err on the side of caution and charge higher premiums.)
*  Confusion about how much they will be charged for their share of the premium. (They will be subsidized, but the amount of the subsidy will vary according to their age, income, geographic location, family size, and choice of plan.)
*  Insurance plans that cover a bunch of stuff they don’t want or need.
*  No reliable source of personalized information. (Ever tried to call the Medicare helpline?)
Finally, they will realize that they don’t need to go through all this. They can delay making a decision until they really need to get health care services:
*  Exchange coverage is guaranteed to accept them at any time with no questions asked.
*  They can save a whole lot of money by not paying premiums and using that money for more pressing needs.
*  There is no meaningful penalty for failing to enroll. What penalty there is applies only to people who make enough money to pay income taxes, and it can be collected only by seizing whatever tax return is due the taxpayer. This can be easily avoided by upping deductions at the start of the year.
Most people have very few medical expenses in the course of a year. According to this chart 50% of the people in the United States consume only 3.9% of all health care expenses each year, while the top 20% consume 78.3%. People in the top 20% will certainly want to be covered but the bottom 50% get no advantage from insurance coverage. They spend far less on services than they would on insurance premiums.
(Scandlen includes here a slide taken from a presentation on “Medicare for All” by Paul Y. Song, MD of Physicians for a National Health Program, graphically demonstrating this distribution of health care consumption.)
Obviously not everyone will make the choice to go uninsured. People who are risk-adverse, or who have ongoing medical needs, or who have small children, will continue to be covered. But every year, every person will have to decide how best to spend their money. A very large number will decide they have better things to do with that money than spend it on insurance coverage they don’t want and never use.
The odds are that after all the trauma and expense of enacting and implementing ObamaCare, we will have fewer people insured than we did before it was enacted.
http://healthblog.ncpa.org/the-crown-jewel-of-obamacare-failures-2/

Greg Scandlen is a very well informed and respected member of the policy community who has been associated with conservative/libertarian organizations such as the National Center for Policy Analysis, Cato Institute, Galen Institute and Heartland Institute. This article for NCPA is presented in its entirety to demonstrate how much agreement there is with those of us at Physicians for a National Health Program in defining some of the problems with the highly flawed Affordable Care Act (Obamacare). This article could have been written by one of us at PNHP.
He does not offer any solutions in this particular article, though had he, it would undoubtedly be from his area of expertise and advocacy – consumer-driven health care, including health savings accounts and health reimbursement arrangements. That, of course, is quite a contrast from the single payer solution advanced by PNHP.
When there is so much agreement on what is wrong, why can’t we agree on the solution? Perhaps it’s our respective goals. We at PNHP want everyone to have affordable access to all essential health care services, as a matter of social justice. The advocates of consumer-driven health care seem to place the will of the individual consumer above that of society’s collective will for health care justice. But the divide is not quite that simple.
Supporters of an improved Medicare for all still agree that the patient (health care consumer) should make the ultimate decisions on his or her individual health care, after being informed on the options. The role of the government is to remove the financial barriers to that care.
The consumer-driven advocates would add to the health care consumer (patient) the responsibility of making spending decisions so that they would shop for higher quality and greater value. The role of the government would be to ensure access to basic health care services for those who lack the financial resources to pay for that care.
The problem with the consumer-driven approach is that is what we have now, and it isn’t working. Except for a marginal tax benefit, it doesn’t matter whether the patient’s share of cost comes from a health savings account or from other personal funds. The system perpetuates uninsurance and under-insurance which exposes far too many to financial hardship in the face of medical need.
An improved Medicare for all would eliminate financial hardship for individual patients while using public policies to reduce the excessive escalation of our collective health care spending. The latter is a task that our private insurers cannot master, but is ideally suited to a single, national, publicly-administered insurance risk pool.
Greg Scandlen understands this. He understands the inadequacies of his consumer-directed approach. I wish he could explain to us better, in terms devoid of ideology, just what is wrong with our approach – an approach that would provide everyone the care that they need in a progressively-financed system that we can all afford.

Analysis finds big state-by-state swings in prescription coverage

By Sam Baker
The Hill, December 4, 2012
President Obama’s signature healthcare law requires insurance plans to cover a range of prescription drugs, but the number of drugs covered will vary widely from state to state, according to a new analysis from Avalere Health.
Based on its analysis of state benchmark plans, Avalere said some states cover as little as 45 percent of available drugs, while others cover more than 99 percent.
“This means that … linking drug coverage to the benchmark formulary will result in drastically different coverage requirements state-to-state,” Avalere said.
http://thehill.com/blogs/healthwatch/health-reform-implementation/270829…
Map of state variations in number of drugs covered:
http://www.avalerehealth.net/news/spotlight/Avalere_Benchmark_Formulary_…
And…

Obamacare architect leaves White House for pharmaceutical industry job

By Glenn Greenwald
The Guardian, December 5, 2012
When the legislation that became known as “Obamacare” was first drafted, the key legislator was the Democratic Chairman of the Senate Finance Committee, Max Baucus, whose committee took the lead in drafting the legislation. As Baucus himself repeatedly boasted, the architect of that legislation was Elizabeth Folwer, his chief health policy counsel; indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it.
What was most amazing about all of that was that, before joining Baucus’ office as the point person for the health care bill, Fowler was the Vice President for Public Policy and External Affairs (i.e. informal lobbying) at WellPoint, the nation’s largest health insurance provider (before going to WellPoint, as well as after, Folwer had worked as Baucus’ top health care aide).
More amazingly still, when the Obama White House needed someone to oversee implementation of Obamacare after the bill passed, it chose … Liz Fowler.
Now, as Politico’s “Influence” column briefly noted on Tuesday, Fowler is once again passing through the deeply corrupting revolving door as she leaves the Obama administration to return to the loving and lucrative arms of the private health care industry: “Elizabeth Fowler is leaving the White House for a senior-level position leading ‘global health policy’ at (pharmaceutical giant) Johnson & Johnson’s government affairs and policy group.”
It’s difficult to find someone who embodies the sleazy, anti-democratic, corporatist revolving door that greases Washington as shamelessly and purely as Liz Fowler.
http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lob…

A well designed, national, single payer financing system would ensure that everyone would receive whatever appropriate drugs they might need. Instead, we have an inefficient, fragmented, costly financing system that imposes regulatory and financial barriers in the way of many needed medications, in a manner inconsistent from state to state.
Congress and the President could have consulted with those fine folks at Physicians for a National Health Program, and then we would have a system that serves the needs of patients. Instead, they consulted a “sleazy, anti-democratic, corporatist,” Liz Fowler, who orchestrated a program that instead primarily serves the needs of the insurance and pharmaceutical industries. She had previously played a key role in the 2003 Medicare Prescription Drug Act (MMA), a program that prohibits government contracting for drugs under Part D of Medicare. She entered the revolving door as a pawn of the insurance industry and departs as a pawn of the pharmaceutical industry – the very industries for which she wrote the legislation.
Shame.
We can change it.

Medical practices wary of insurer efforts on new payment programs

By Victoria Stagg Elliott
American Medical News, December 3, 2012

Medical practices have a low opinion of how insurers are operating emerging payment programs, such as accountable care organizations, patient-centered medical homes, shared savings and payment bundling, according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.

Researchers asked practices to rate the willingness of seven large payers to engage in innovative models on a scale of one, meaning completely unwilling, to five, which indicates completely willing. Medicare Part B scored the highest at 1.95, and United Healthcare was the highest private payer at 1.82.

When asked to rate the favorability of these payment models to the practice on a scale of one to five, Medicare Part B scored highest at 1.68.

Health industry insiders said the scores on innovative payment models reflect physicians’ frustrations with programs they believe were not designed for their specialty or size, and that insurers were not flexible in negotiating terms.

ACOs serve 25 million to 31 million patients, a “remarkable achievement for a care arrangement that was scarcely on the map at all two years ago,” according to a report released Nov. 26 by management consulting company Oliver Wyman.

Cigna’s collaborative accountable care program includes 42 participating entities, mostly large, with about 10,000 physicians providing care for 400,000 members. A paper in the November Health Affairs found the plan’s ACO program improved quality and lowered costs.

http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20121203

And…

Practice Perspectives on Payer Performance, 2012

MGMA-ACMPE

For the fifth year in a row, the Medical Group Management Association (MGMA) has conducted its poll to determine group practice professionals’ attitudes about payer interactions.

Of the payers who are willing to engage in innovative payment models (accountable care, shared savings, medical homes or payment bundling), how favorable or unfavorable do you consider these options to be to your practice?

Rating average / Payer

1.68  Medicare Part B
1.62  United Healthcare
1.62  Aetna
1.58  Cigna
1.57  Anthem
1.55  Humana
1.48  Coventry

(Based upon a 5 point scale where 1 = Completely unfavorable, 2 = Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 = Completely favorable.)

http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1372690

And…

A Collaborative Accountable Care Model In Three Practices Showed Promising Early Results On Costs And Quality Of Care

By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen Kennedy, Robert C. Flores and Alan M. Muney
Health Affairs, November 2012

Cigna’s Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans.

Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care.

http://content.healthaffairs.org/content/31/11/2379.abstract

Comment:

By Don McCanne, MD

These early results should sound the alarms on our current efforts to implement accountable care organizations (ACOs). We’ve barely begun and already about 30 million patients have been assigned to ACOs. Yet look at how that is working.

Health care professionals in group practices were polled on how favorable or unfavorable the insurers’ innovative payment models, primarily ACOs, were to their practices. The average rating for all insurers was in the 1s – “completely unfavorable”!

Further, we are now seeing the same response from the insurers that we did with earlier efforts at managed care. They were telling us then that we were receiving higher quality care at lower cost. As it turned out, costs continued to rise and quality remained mediocre.

Now Cigna is reporting that the recent Health Affairs article that they authored showed that their “ACO program improved quality and lowered costs.” Yet the article actually states that these early results were “not statistically significant.”

This turkey has already taken off, and yet it can’t fly. The health care of 30 million patients is already at stake, and they are being cared for health care professionals who find the arrangement COMPLETELY UNFAVORABLE!

Medical practices wary of insurer efforts on new payment programs

By Victoria Stagg Elliott
American Medical News, December 3, 2012
Medical practices have a low opinion of how insurers are operating emerging payment programs, such as accountable care organizations, patient-centered medical homes, shared savings and payment bundling, according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.
Researchers asked practices to rate the willingness of seven large payers to engage in innovative models on a scale of one, meaning completely unwilling, to five, which indicates completely willing. Medicare Part B scored the highest at 1.95, and United Healthcare was the highest private payer at 1.82.
When asked to rate the favorability of these payment models to the practice on a scale of one to five, Medicare Part B scored highest at 1.68.
Health industry insiders said the scores on innovative payment models reflect physicians’ frustrations with programs they believe were not designed for their specialty or size, and that insurers were not flexible in negotiating terms.
ACOs serve 25 million to 31 million patients, a “remarkable achievement for a care arrangement that was scarcely on the map at all two years ago,” according to a report released Nov. 26 by management consulting company Oliver Wyman.
Cigna’s collaborative accountable care program includes 42 participating entities, mostly large, with about 10,000 physicians providing care for 400,000 members. A paper in the November Health Affairs found the plan’s ACO program improved quality and lowered costs.
http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwlt…
And…

Practice Perspectives on Payer Performance, 2012

MGMA-ACMPE
For the fifth year in a row, the Medical Group Management Association (MGMA) has conducted its poll to determine group practice professionals’ attitudes about payer interactions.
Of the payers who are willing to engage in innovative payment models (accountable care, shared savings, medical homes or payment bundling), how favorable or unfavorable do you consider these options to be to your practice?
Rating average / Payer
1.68  Medicare Part B
1.62  United Healthcare
1.62  Aetna
1.58  Cigna
1.57  Anthem
1.55  Humana
1.48  Coventry
(Based upon a 5 point scale where 1 = Completely unfavorable, 2 = Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 = Completely favorable.)
http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1372690
And…

A Collaborative Accountable Care Model In Three Practices Showed Promising Early Results On Costs And Quality Of Care

By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen Kennedy, Robert C. Flores and Alan M. Muney
Health Affairs, November 2012
Cigna’s Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans.
Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care.
http://content.healthaffairs.org/content/31/11/2379.abstract

These early results should sound the alarms on our current efforts to implement accountable care organizations (ACOs). We’ve barely begun and already about 30 million patients have been assigned to ACOs. Yet look at how that is working.
Health care professionals in group practices were polled on how favorable or unfavorable the insurers’ innovative payment models, primarily ACOs, were to their practices. The average rating for all insurers was in the 1s – “completely unfavorable”!
Further, we are now seeing the same response from the insurers that we did with earlier efforts at managed care. They were telling us then that we were receiving higher quality care at lower cost. As it turned out, costs continued to rise and quality remained mediocre.
Now Cigna is reporting that the recent Health Affairs article that they authored showed that their “ACO program improved quality and lowered costs.” Yet the article actually states that these early results were “not statistically significant.”
This turkey has already taken off, and yet it can’t fly. The health care of 30 million patients is already at stake, and they are being cared for health care professionals who find the arrangement COMPLETELY UNFAVORABLE!