“It’s Hard Work, but It’s Good for the Soul”: Accountable Care in the Trenches

From Brigham and Women’s Hospital, Boston, MA.

I have always grazed on the medical commons [1]. My practice style was “accountable” years before I even knew what that meant. It wasn’t a conscious choice. It certainly wasn’t a statement about how the school district where my mom worked couldn’t afford to hire new teachers because of the rising cost of health care. When I finished medical training in 1991, I was more worried about killing a patient than about the patient losing health insurance if they left their job to start a business, let alone the downstream effects of that on the US economy.

I’ve just always had a value practice style. I never liked hospitals. I’m proud of my control issues, and there were just too many people, too much chaos, and too many opportunities for a medical error in the hospital. And it always seemed to me that most patients would rather feel lousy in their own bed, with a home-cooked meal and their family near, than in a hospital surrounded by strangers eating lousy food on an uncomfortable mattress (remember, I’m talking the 90s).

But my value bent is not just pro-home and anti-hospital. It’s my personal aesthetic of care. I enjoy the intellectual challenge of figuring out the right test to use to answer the question fastest with the least inconvenience for the patient. There is nothing quite like hitting upon the exact right medication regimen for a depressed alcoholic hypertensive diabetic patient with COPD and gout. And oh the joy when the patient calls and says their abdominal pain resolved on its own, meaning your plan to use watchful waiting rather than order an expensive abdominal CT of uncertain benefit saved the patient from unnecessary harm. Volume-driven care is a temptation to lazy thinking. Why would I want to do that?

I’ve been practicing for 23 years. I spent the bulk of my career practicing in what was arguably, in its time, the best Medicare ACO in the country—before anyone had invented the idea of an ACO [2]. I also led its department of general internal medicine in 2004 when the clinic decided to dis-integrate and de-capitate—transition from single-payer capitation to multipayer fee-for-service (oops!). In 2008, trying to understand why no medical students wanted to do what I love doing (being a general internist), I moved to an academic medical system and found myself back in the heart of fee-for-service medicine. And now, completing the circle, that same academic medical system is in the process of trying to move from volume to value, signing up to become a Medicare Pioneer ACO as well as entering into the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract [3].