CHEST Topics in Practice Management Topics in Practice Management

In the 1990s, health maintenance organizations were touted as the solution to the health-care cost/quality conundrum. By focusing on both the price and espe-cially the volume of health-care services, managed-care programs were able to moderate cost growth for a time. But Americans bristled at the restrictions of the plans, which were at times heavy handed. The ensuing patient and provider backlash prevented the whole-sale conversion to managed care that many had pre-dicted. Nevertheless, Medicare managed care, now called Medicare Advantage, remains a signifi cant fea-ture of the health-care landscape, and has served in some cases as a laboratory for innovation. Although services provided directly by primary care physicians (PCPs) account for a small fraction of health-care payments, the referrals and decisions PCPs make are powerful drivers of overall costs. Managed-care organizations understood this relationship and struc-tured care delivery around the “gatekeeper ” model whereby patients were required to choose a PCP, who could infl uence utilization. In return, some payers promised to reward quality and cost effectiveness, a scenario that had signifi cant appeal for PCPs disen-chanted with payment under the resource-based rel-ative value scale. Our experience with Medicare Advantage leads us to believe that substantial savings can be realized through the reduction of avoidable and low-value care, even without the referral requirements and closed network structure typically encountered in managed-care programs. Medicare’s Accountable Care Orga-nization (ACO) program offers the opportunity to test competencies developed through engagement with Medicare Advantage, in a “kinder, gentler ” frame-work in which patients enjoy the same freedom of choice as they do in traditional Medicare