I had a silver-and-gold Passover. Hearkening back to the old Girl Scout song I learned from my mother:

Make new friends, but keep the old;
One is silver and the other’s gold.

With no space or equipment to have a seder myself, I was nevertheless the lucky recipient of not just one, but two invitations. The gold was thanks to a quarter-century-plus friendship; the silver was from a family we met the week before Passover. Who should I meet at the seder but a legitimate health policy guru, with whom I promptly struck up the first of hopefully many spirited discussions on the state of health care in the U.S. today.

How would you fix it? I asked him.

He responded that he would allow any payment structure at all, except fee-for-service, which he would outlaw.

What’s so terrible about fee-for-service? Doesn’t nearly every other private enterprise in the country operate on the basis of paying for services rendered?

He replied, “But with fee-for-service, there’s no accountability.”

Accountability. I do not think that means what you think it means.

Accountability, according to Dictionary.com,  is “the state of being liable or answerable.”

Being answerable presumably means that when something goes wrong, he who is accountable is the go-to guy for blame. The bit about “liable” would imply a monetary dimension to the exchange.

What does this mean in medical terms? When something goes wrong, someone has to pay? Sounds rather like a rallying cry for the plaintiff’s bar. The problem is that in medicine, the line between doing something wrong and something bad happening is far less straight than may be imagined.

Another issue is that bad things often happen to people which is no one’s fault. Tumors metastasize; organs fail; people even die. (Actually, all of them will eventually.) Where does accountability come into it?

The health care policy guru’s answer: chronic disease management. Diabetes, hypertension, chronic heart, lung, and kidney disease cost way too much. Ostensibly way more than they should. (According to whom, by the way?) When physicians are held accountable for the costs of the medical care they provide, so goes the theory, they will provide … what? Better care? More evidence-based based? More efficient?

We then run smack into the fact that so much of the response to treatment depends on the patient. What about people who keep smoking, refuse to exercise, eat whatever they want? To non-physicians, this is still our fault. “Education” is the perennial answer. Obviously if we had appropriately educated, the patient would comply with our recommendations and get better. At what point are patients ever accountable for themselves?

Apparently the only kind of accountability that counts (at least to health care policy gurus) is for physicians to be associated with organizations that take financial responsibility (also known as risk) for the costs of medical care. And of course, the only reasonable way to take on that kind of risk is to be  part of a very large organization, and assume responsibility for a very large number of people (or, in other words, a population).

These accountable care organizations nothing more than managed care 2.0, resurrecting the failed debacle of managed care from the 1990s, but with more money thrown at them this time around. I’m not holding my breath to see how many of those dollars trickle down to people actually providing medical care to people who are sick and hurt (known respectively as doctors and patients.)

When you stop to think about it, true fee-for-service makes me ultimately accountable to the only person who really matters: my patient. Once you take both government and insurance companies out of the middle (the so-called “direct pay” model, where the patients pay me directly for my services) and it’s just me and them, only then am I truly accountable.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.