From Barney Fife to Steve Austin

A wise person (or a plain old wise guy — depending on your definition) once opined that insanity is when you endlessly repeat the same behavior, yet expect different results. Watching the growing discussion of Accountable Care Organizations (ACOs), I wonder if our friends in Washington, D.C., think that they can wring a different result out of the old capitation model simply by moving the nucleus from the provider’s office to a broader setting.

In the good-old, bad-old days of the 1990s, someone decided that paying providers on a capitated basis would deliver better quality healthcare. Providers receiving a fixed dollar amount per patient, they reasoned, would have an incentive to keep their patients well. If a patient did not need too much care during the year, the physician would come out ahead. Of course, we’ll pay them less, and they’ll do more. Yeah…that’s the ticket. Works every time!

Proponents of ACOs seem to have taken their cue from the old “Six Million Dollar Man” series. In the beginning of every episode, Oscar Goldman (played by Richard Anderson) says, “Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world’s first bionic man. Steve Austin will be that man. Better than he was before. Better, stronger, faster.”

Attempting to rebuild the existing system with monetary sticks and carrots belies the need for real systemic reform. The fundamental IPA model is inefficient and expensive in the extreme and needs transformation, not reformation. The medical establishment knows how to craft a model that achieves the twin goals of efficiency and effectiveness. They don’t need the government or regulators to goad them into it; they just need patients to demand it.

Putting Barney Fife in a tuxedo won’t make him into Steve Austin.