While waiting for Dr. “Mosty” Mostashari to reply to my heartfelt love note, I started reading the second part of his Medical Economics interview, but it was late and I must have dozed off.
Later while running through the airport, I stopped to check on my flight to find that, again, it was delayed. Resigned, I slumped on to the nearest bar stool and ordered a tall one to toast a wasted afternoon. I started to go back to the latest copy of Medical Economics, and had to do a double-take – I was sitting right next to Dr. Farzad Mostashari, MedEc’s latest dream date poster boy.
“Can I help you?” he asked indifferently. I guess I had been staring. I introduced myself, and asked whether he had gotten the letter I had written last week about all the big work he had done as the national HIT commissar. He replied, “No, my staff handles my correspondence, I am much too busy to address trivial complaints. Now if you don’t mind…”
“Doc, Part 2 of your interview described you as a ‘staunch advocate for independent medical practices’ – are you?”
“Of course I am!” he replied, “I’m the CEO of Aledade, a company where we ‘offer independent primary care physicians access to ACO’s and the accompanying benefits of partnering with others to improve patient health care.'”
“Wow, that’s a pretty big deal. So you get paid by herding physicians into compliance with other laws, kinda like you did with Meaningful Use, huh?”
Mostashari look puzzled. “Not at all!” he replied rather indignantly, ” ‘For all of its faults, one thing Meaningful Use did accomplish was that we moved off of paper. And as bad as some of the usability issues are with the [electronic health records (EHRs)] today, I don’t see people going back to paper.’ Moreover, ACO’s are voluntary.”
Not a bad IPA, I thought, heavy on the hops up front, but mellow in the middle. I signaled the bartender. “Doc, it might surprise you to know that we literally use a lot more paper than we used to in our small-town hospitals since we went ‘all-electronic.’ And these ACO’s…aren’t they really just another way for you to simultaneously exert greater control over larger numbers of physicians, while skewing the industry in favor of larger groups?”
Mostashari was ready: ” ‘I know that there is a policy concern that we – not unwittingly, perhaps – push practices into consolidating with health systems. This is a serious policy problem because when independent practices go away, when there’s no longer any local competition, what happens is costs go up.’ ”
“You mean, push independents into consolidating because YOU drove up their costs, with all those expensive EHR’s that no one wanted, and the Meaningful Use that meant we would get screwed, and the onerous quality reporting systems that jacked up our overheads far above the piddly return bonuses?”
Mostashari shook his head, “Not at all. ‘The best advice is when you find yourself in a hole, stop digging. Medicare, I believe, is going to do the right thing and is going to change.’ ”
I countered, “You mean go Direct Primary Care? By the way, what’s that pink stuff you’re drinking?”
“It’s a gluten-free elderberry Cosmopolitan, why? They’re very popular at the club. Anyway, Direct Primary Care isn’t a solution. ‘At the end of the day, independent practices who take on the challenge of not shrinking into their shell but actually realizing their power and reach outside of their walls can say, ‘No, I can exert influence on the patient’s total care.’ ”
“What if I don’t want to be responsible for anyone’s ‘total care’?” I asked. He made a let-them-eat-cake wave: ” ‘I’m going to be patient centered, not centered on my four little walls.’ ”
“Look Mosty” I asked, “What exactly does “independent” mean to you?”
He gave me a professorial squint. ” ‘Anyone who’s independent knows why they’re independent … they value the autonomy and they value the ability to do what they believe is best for the patient, not corporate medicine interests.’ ”
“You didn’t answer my question”, I said.
” ‘We can be independent, but we can’t be autonomous.’ ” he said.
“You don’t actually practice anymore, do you?” I asked skeptically.
“Oh I understand ‘the burdens of dealing with the complexity and the cost and price pressures of remaining independent…You can retire. The number one thing I hear from docs when they’re considering retiring is: ‘What happens to my patients?’ Which is such an expression of selflessness in the profession.’ ”
“Look Mosty – you sure you don’t want a beer? – why would anyone stay in this abuse if they could escape?”
“No thank you” he replied, “I don’t drink … beer. And you’re wrong about health care. ‘Under population health, there’s a whole new set of technology issues, of new kinds of things that expectations are, accountability for things you don’t control. This is hard but it’s worth doing …. That is incredibly rewarding. It lets you practice medicine the way you wanted to practice medicine. But it also gives you more control.’ ”
“Listen Mosty, for the sake of argument, let’s say you are not a self-serving technocrat who is making serious money off the colleagues you helped stuff into this trap in the first place. What are you doing to encourage physicians to be truly independent, so that government doesn’t dictate they way they practice?”
Mostashari swirled his pink cocktail, then fixed me with a serious eye: ” ‘ It makes no sense for our primary care practices, for example, to be in a risk model where they could lose their practice if there’s some actuarial swing in the total cost of care. You need to provide downside protection to those small practices. Medicare can do it. Medicare should do it.’ ”
I continued, “But YOU added to that ‘actuarial swing’ in costs! And what about these stupid, unproven quality targets you brainiacs keep using to deny payment?”
Mostashari smiled, waving away my concern: ” ‘ For example, half of the points of your clinical practice improvement are automatically granted. Your quality scores are automatically taken care of by the ACO’s quality report as a group
I was getting exasperated. “But Medicare is the very culprit keeping rates flat while laying on all these stupid new regulations that increase overhead!”
Mosty gave me his most patronizing smile, tut-tutting at my irritation: ” ‘I’m encouraged that there does seem to be more out-of-the-box thinking in Medicare and with things like the Presidential Innovation Fellows and the U.S. digital service [start-up]. Maybe these Silicon Valley geniuses who are coming into do a stint in government, maybe they can help them figure out a way to have a shorter than two-year time frame to put in place the system changes.’ ”
It was my turn to be thoughtful. I offered, “So being independent will actually mean being in a larger group?”
He practically beamed: ” ‘Those practices who stay independent and band together and enter into total cost of care contracts and do well in them are going to be a magnet for pulling more docs out of employment and keeping them independent. So I’m actually optimistic about this.’ ”
“So what you’re really saying is that physicians are screwed either way.”
” ‘The revenue is not guaranteed.’ ” Mostashari suddenly looked suspicious, and asked, “Are you just pulling actual quotes from my interview and rearranging them in some sophomoric way to make me look bad while making your own points?”
And then I woke up. It was time to go to work, the Medical Economics interview had given me bad dreams, and I guessed that being hung over on the expensive elderberry liqueur of ACO’s would ultimately be no better than the headaches and debt from cheap-HMO whiskey.