What’s In Your ACO? by Pat Conrad MD


How did getting paid for a rendered service become: “It was about the Yin and Yang of payment reform and delivery transformation.” This actual quote from Farzad Mostashari, MD leads off an interview in which the fawning interviewer described him as “a champion of the provider.” A champion??

She asks how he would help the little guy, and he responds by putting everything in a MACRA context, saying simultaneously that no one can remain autonomous, and banding together into larger ACO’s won’t “change your independence.” And one bands together using services from his company, Aledade, which he will be hawking at the next AAFP mass blind grope. It’s a fine, nonsensical point to imagine autonomy and independence being at odds, but I guess you can’t make millions without breaking a few non sequiturs.

FM tells us that you can be an employee, retire, check out (does he mean suicide?), or band together. He advocates the “third way” of banding together, and utterly dismisses the actual fourth way of DPC. FM relies on the insidious device of combining fear with a single plausible escape route, His Way: turning to fight Goliath by first discarding all fee-for-service arrangements in favor of so-called “value based” care, which requires embracing “population health.” But what if the autono-, sorry, the would-be independent doesn’t want to become a population health practitioner? The fawning interviewer never asks and FM never says, so I guess the answer is “too bad.”

FM actually recommends the following:

  1. “Generate insight of your data
  2. Make that data accessible for insight.
  3. Create a learning infrastructure (like I’m doing here) – experiment, instrument your interventions and outcomes. Learn from yourself.”

I laughed out loud reading that. And how exactly does this NOT scream, “Sell your data”? No wait, he then said: “There is a commitment on the part of CMS to get it right –and their [sic] going to continue to work to get it right.”

Mosty says there are three types of care (with my parenthetical explanations):

  1. Managed Care – Lots of benefit design, who you can see, what you can get, what you can’t get (failed in the 1990’s, got a new acronym).
  2. Totally Unmanaged Care – FFS, PPO – go wherever you want. The patient is the manager” (But we’ll pay you less all the time, so you’re screwed).
  3. Something in the Middle – someone to accountable [sic] for you and make you accountable in a soft way, to nudge you” (the way to keep doing #1, by pretending its an improved #2, which will make us more money and leave you just as unhappy).”

To which I add:

4. Direct Primary Care – The only care delivery system consistent with the Hippocratic Oath, the only one that can provide actual independence for both patient and physician, and therefore the one that will provide the best actual care.

5. Single-Payer Care – Which is where all this is heading, don’t kid yourself. Then I will demonstrate for you the true meaning of “lazy.”

6. Nurse Practitioner Care – which is all that will be left.

7. Don’t Care – Hey, those fish aren’t going to catch themselves.

Mostashari is like Dr. Baron, ABIM CEO, and Dr. Puffer ABFM CEO, the AMA, AAFP, and so, so many others – they are making big, big $$ as quasi-government stooges, licking their masters’ hands while telling actual practicing physicians what is best for them, and what the public demands, the same moron public that can’t figure out why health insurance costs skyrocketed, but can name every member of the Kardashian family. These bastards play to the desire of politicians (and their corporate cronies) to control people by agreeing in long studies and longer self-congratulatory seminars that yes, we must have “quality” and “value”, then turn around and tell us that they know exactly how this feels and here is what the rest of us must do to survive and thrive, only for a small fee here and there, for our own good, because nothing guarantees quality and value like periodic board recertification and collating small practice data to sell to larger groups in return for avoiding Medicare penalties. Go to this AAFP site and look at Mosty’s charts, graphic assumptions and arbitrary design assertions, all designed to get more “private” docs to pay him more money while being further trapped by the government, while telling each other that they are really independent. I’m telling you, go look at these charts for yourself. I won’t hog up your valuable bathroom time by trying to explain all that is outrageously soul-strangling in so many of these slides, but they alone should be enough to discourage anyone from going into medicine.

Mosty ignores a couple salient points:

  1. Medicare has been financially insolvent since 1972.
  2. The unrestrained demand that comes from an open-ended entitlement enjoyed by an increasingly graying population means that Medicare will never be financially self-sustaining, and no actual program reform is politically palatable.
  3. Even if the arbitrary garbage notion of “quality” were true, it would only lead to MORE longevity for seniors, which would lead to MORE demand, leading to MORE Medicare expenditure, resulting in even more cost overruns, causing MORE need for “cost consciousness”, naturally requiring MORE penalties for doctors and hospitals to cut costs.

The primary practice of Mosty’s Compassionates is to sell compliance, a form of fear akin to the ubiquitous gold hawkers populating cable TV, and their primary procedure is the wallet biopsy & excision.

Dr. Mostashari, I hope someone, somehow gets this blog to you. I hope you realize that some of us know that you went from being a bully who helped the government extort money from physicians to being a bad private-sector, thoroughly unprincipled opportunist trying to sell us a hedge that will continually decrease in value in an unbeatable system, while you line your pockets. You are one of the shadow czars who made health care worse for everyone. This is not about patient care or practice independence. This is simply about buying your next beach house where you can spend vacations trying to dream up a new way to sell gold to whatever suckers are left.