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This Is Uncomfortable

Playing hardball: doctors start negotiating with doctors

Dan Gorenstein Oct 26, 2016
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Lefteris Pitarakis - WPA Pool/Getty Images

Since the introduction of Obamacare, a growing number of physicians are part of what are called Accountable Care Organizations, where physicians, nurses and other providers are responsible for the health of their patients and the costs of that care.

The shifting landscape is rearranging incentives, and leading doctors into corners of their work they’ve rarely visited.

On a late Friday afternoon last month, the Family Health Associates practice in Charleston, West Virginia is empty.

Empty except for Dr. Julie DeTemple and her staff.

“I should be home and I’m here typing away doing my notes, charting,” DeTemple said.

The primary care doctor has had to adjust from examining patients – why she got into the business – to examining data.

Her quality time with spreadsheets has ramped up this year, now that’s she’s co-founded the Aledade West Virginia ACO, made up of 11 physician practices in the state.

The physicians constantly meet, looking for ways to improve care and cut out wasteful spending.

This summer, colleagues flagged DeTemple’s lab costs.

“I thought that’s crazy because I don’t feel like I order an unusual amount of labs,” she said.

DeTemple was right, she wasn’t.

A nephrologist in town, a kidney disease specialist she’d been referring patients to forever, was responsible for the spike.

He was ordering lots of lab work and duplicating tests she’d already ordered.

So DeTemple did something she’d never had to do in her 15-year career: she issued an ultimatum.

“I was like, look we can either fix this, or I’ll have to send people to a different nephrologist,” she said.

She told him what he’d been doing wouldn’t fly anymore.  

“In the future I’m going to get paid based on how well I take care of the patient and on how much money I save,” she said. “So if somebody else is spending money out of my patients’ pot unnecessarily, I’m not going to get paid.”

“I was surprised and glad she informed me right away,” Dr. Julian Espiritu, the nephrologist, said.

Espiritu said in the days before this new ACO, it was a “I do what’s best for me, she does what’s best for her” kind of approach.

But he recognizes those days are over.

Nephrologist Julian Espiritu has agreed to order fewer tests after the ACO confronted him.

Nephrologist Julian Espiritu has agreed to order fewer tests after the ACO confronted him.

“Now we have one pot and we have to respect that pot. Someone who uses too many cookies is going to be unwelcome,” he said.

Espiritu has put his money where his mouth is.

He’s cut way back on all the tests, at least for the patients enrolled in the ACO.

And his billing has dropped more than 50 percent according to ACO data.

This is kind of how people dreamed ACOs would work, with primary care doctors like DeTemple shopping around for specialists to find good value.

“That’s what we’re doing. Every practice is looking to see who can deliver quality care while giving the bests costs,” DeTemple said.

ACOs have yet to deliver on the kinds of efficiencies that supporters have predicted for years.

But DeTemple’s experience shows when you give primary care doctors an incentive, they are in a position to trip over waste and crack down.

Read part one in our two-part series on how health care, in the wake of the Affordable Care Act, is changing the lives of patients and doctors.

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