ACOs may need a lift from Spider-Man


Just in case you were wondering how CMS chief Dr. Donald Berwick views accountable care organizations, something he said recently offered a glimpse of their potential. He invoked the cartoon superhero Spider-Man when discussing ACOs during a workshop earlier this month in Washington, D.C.

He was in the midst of discussing how life throws a curveball at everyone at some point or another. That's when you learn you've been diagnosed with something like cancer, diabetes or the threat of a stroke. Maybe your child has asthma or your mother macular degeneration.

At points like that, modern healthcare has the huge potential to help and heal, but it has nearly equal potential to confuse and harm you, Berwick said. "Spider-Man says, 'With great power comes great responsibility,'" he said. "Medicine has power. Who has the responsibility? Who's got your back?"

That's where the whole integrated care model steps in. The term ACO, he said, is just a label for a deeper idea that we all need stewards to help us make sense of the complexity of modern medical care. By "we," he was referring to not just patients and families, but caregivers and clinicians.

Then he gave an example of integrated care he encountered during his 20 years practicing pediatrics with the Harvard Community Health Plan, which could have been called an ACO, if the system existed today.

At the time, he was practicing with seven other pediatricians, who served an inner city population in the Boston area. He walked into the consulting room and met Timmy, a 5-year-old child who was breathing heavily, having an acute asthma attack. He was clearly quite sick.

If Berwick had taken the path well-traveled, he would have immediately sent the boy to the ER of the children's hospital. But the story took a different turn.

Before Berwick started to speak, Timmy's young mother gave him a chart of the boy's breathing tests at home, his FEV1, his forced expiratory volume in the first second, which a visiting nurse had taught her to measure at home with a simple machine. The mother had been keeping a chart and responding at home immediately by adjusting the boy's medications. She said she thought Timmy needed a different medication that she didn't have at home and wanted to know if they could try it.

Just as Berwick began to respond, someone knocked on the door and the chief of allergy for the multispecialty clinic walked in, with a vial of exactly the medicine the mother had just mentioned.

Turns out Timmy's mother had spoken with the visiting nurse, who was also employed by the ACO, who called the allergist as the mother came to the office. Berwick wasn't too surprised by what transpired, because someone had handed him the EMR when he entered the room.

Within 10 minutes, Timmy got the new medicine and an hour later he was headed home, in much better shape, with a nurse scheduled to check up on him at home that afternoon.

There was no rush to the emergency department, no hospital stay, no scary trip for a young child. And all that came at a lower cost for everyone, Berwick said. "That is integrated care," he said. "And every single person in America can have it if we play our cards right. If we keep our wits about us we can build it."

I hope he is right. But let's be realistic. We may need Spidey's superpowers to actually get ACOs off the ground. - Sandra

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