Another Perspective on Accountable Care Organizations


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Accountable care organizations are even more concerning as they fundamentally alter the relationship between the patient and the doctor.

—Jonathan Schwartz, MD

I read with great interest Dr. Richard Boxer’s editorial on accountable care organizations in the January 15 issue of The ASCO Post. Much of what he says is unfortunately true. There are several points that I would like to make, however.

First of all, Dr. Boxer states that the “principle that defines the reason for accountable care organizations is … that health care in America … demands creative reform.” Accountable care organizations are hardly a new or creative idea. The insurance industry made similar attempts in the late 1990s and early 2000s to develop a system based on the doctrine of “each according to his ability, to each according to his needs.”

Solutions Doomed to Failure

The capitation of 10 years ago generally failed because (1) patients hated it, (2) our internal medicine colleagues were not trained or equipped to understand the subtleties of subspecialty care and thus were not the “gatekeepers” envisioned by the utopian planners, and (3) it did not save money.

Secondly, accountable care organizations and their cousins in the Affordable Care Act are statist solutions, which are neither new nor creative. In fact, they are quite predictably destructive. Statist solutions like Medicare, Medicaid, diagnosis-related groups, electronic medical records, and evidence-based medicine are the reasons we require health-care reform in the first place. Inevitably, all statist solutions eventually fail under their own weight and require further statist solutions to correct their shortcomings. Any system of reform that continuously creates the need for more reform can hardly be considered creative.

Accountable care organizations are even more concerning as they fundamentally alter the relationship between the patient and the doctor. Previously, the doctor’s role had traditionally been as the advocate for the individual patient. Under accountable care organizations, the doctor will no longer be the advocate for the individual, but will be coerced into becoming the advocate for the system.

True Intentions

The true intention of the accountable care system is to ration care under the guise of “evidence-based medicine” and “quality care” with the expressed intent of saving money/resources. Unfortunately, such a cold-hearted, bureaucracy-laden system will inevitably harm many individuals who do not fall into the bell-shaped curve of evidence-based cookbook medicine, especially those with rare and unusual conditions. Is this a system in which we as physicians wish to participate?

Clearly, the people who stand to derive the greatest benefit from this will be the central planners in Washington, DC, and in academia, who stand to gain the power of life-and-death decisions over the individual patient and the doctor. The final frontier of freedom between the individual patient and physician will have been breached forever.

What is truly amazing and at the same time frightening is the silence of our profession and the willing collaboration of so many of our colleagues to support such an immoral system, which will ultimately destroy our profession and irrevocably hurt so many innocent individuals.

Moral Obligation

Again, I call on ASCO to develop committees of truly forward-thinking individuals who seek to develop true creative reforms based on knowledge of the choices of the individual through the free market. This understanding is the only hope for developing a just health-care system.

It is our moral obligation as physicians to maintain our role as defenders of the individual patient against whatever authoritarian system comes along, no matter what the specious justification for that system. ■ 

Jonathan Schwartz, MD
Tucson, Arizona


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