President Obama's vision of health care reform seems destined to move forward now that he's been re-elected; in any case, certain tenets of Obamacare already have been embraced by the private sector — by large employers and insurers — and wouldn't have been threatened even if Republicans had won control of the federal government. But the folks at HHS and CMS know the path to system transformation will involve twists and turns as certain assumptions prove overly optimistic and the inevitable unintended consequence rears its ugly head here and there.


Recent reports challenge two of the reformers' assumptions — that reducing unnecessary emergency department visits will significantly bend the cost curve and that accountable care organizations will meet the main goals that have been set for them.

Are EDs a good deal after all?

Researchers at the Association of Emergency Care Physicians' annual meeting this fall disputed the contention that care delivered in the emergency department is excessively expensive and inefficient. Robert O'Connor, M.D., chair of emergency medicine at the University of Virginia School of Medicine, said EDs account for only 2 percent of the $2.4 trillion spent on health care in the United States each year.

Reporting on the ACEP presentation, The Washington Post's Sarah Kliff noted that the average ED visit costs $922, compared with $199 for a visit to a primary care physician. But researchers have found the vast majority of cases — even among so-called frequent flyers — are for genuine emergencies that need immediate care.

As Kliff quotes ACEP President Andrew Sama: ED doctors are "handling a third of the acute care visits and essentially 50 percent of the decision-making in hospitalizations, whether someone will be admitted or not. I think what we're spending on that seems to be reasonable."

Of course, ACEP has a vested interest in defending emergency department use, but if one of the aims of health care reform is to reduce unnecessary ED visits — a worthy goal, let's all agree — the savings may be relatively minor in the scheme of things.

Do ACOs Stand a Chance?

An article in Health Affairs maintains that accountable care organizations may face the same fate as integrated delivery networks, which came and largely went in the 1990s. And even if ACOs succeed at one of their three intended goals — improving quality of care, improving the health of their populations and controlling costs — they are unlikely to accomplish all three.

Lawton R. Burn and Mark V. Pauly acknowledge that unlike integrated delivery networks, ACOs will have better information technology to work with, that bundled payments will incentivize providers to work together and that hospitals are hiring physicians mostly on an individual basis rather than paying excessive prices for entire practices like they did in the '90s.

However, they say, in most cases providers are no more skilled at coordinating care across the continuum than they've ever been and that doing so for patient populations with multiple chronic conditions is incredibly challenging, that the upfront costs for implementing the necessary IT and otherwise establishing ACOs is daunting, and that demonstration projects for pay-for-performance and care coordination efforts have so far shown no significant cost savings.

Burn and Pauly also say a shortage of primary care physicians is the Achilles heel of ACOs.

The authors cite many examples to back up their claims, and the article goes into much more detail. While it's discouraging, it's worth reading. As they note, "the path to knowledge begins with having realistic expectations."

If we are going to transform health care for the better, let's understand what we're up against and get it right. ACOs — or any other of the worthy principles of reform — can never succeed if they're erected on a wobbly foundation to begin with.