November 19th, 2013

An ‘Iron-Triangle’ of Patients, Providers, and Payers?

Several Cardiology Fellows who are attending AHA.13 in Dallas this week are blogging for CardioExchange. The Fellows include Vimal RamjeeSiqin YeSeth MartinReva Balakrishnan, and  Saurav Chatterjee. You can find the previous post here. For more of our AHA.13 coverage of late-breaking clinical trials, interviews with the authors of the most important research, and blogs from our fellows on the most interesting presentations at the meeting, check out our AHA.13 Headquarters.

For those of us just beginning our careers, I think it’s safe to say that the dramatic changes now underway in the U.S. healthcare system are both exciting and anxiety-provoking.

It was with this in the back of my mind that I attended a talk by Karen Joynt on Sunday evening. Karen, who was my fellow when I was a CCU resident, offered a refreshing perspective on how to think about the ongoing transformations in how healthcare will be delivered.

She pointed out that as fee-for-service payment models are replaced by Accountable Care Organizations (ACOs), the alignment of incentives for insurers, providers, and patients also changes. ACOs’ missions are both to improve quality of care and to lower costs. However, since the payment structure for ACOs more explicitly aligns incentives for providers and insurers, we should also be vigilant for unintended consequences such as risk-aversion and new barriers to access. As an example, she points to her work on how public reporting may have affected the use of PCI in high-risk MI patients.

Her talk also reminded me of last week’s JAMA special article, “The Anatomy of Health Care in the United States,” by Hamilton Moses and colleagues. In the article, the authors discuss an “iron triangle” of priorities among payers (measured effectiveness, access, and cost), clinicians (professionalism, autonomy, science, and technology), and patients (prevention and care, information and unbiased guidance, perceived failure) that are sometimes mutually exclusive. How to negotiate among these priorities is one of the central challenges facing us today.

Although I strongly believe that it is our responsibility as physicians to improve the value of the services we deliver, I found these insights thought-provoking. What is your take on how we can harmonize the conflicting priorities among patients, providers, and payers?

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