Monday, December 10, 2012

On Accountability 

The Accountable Care Act (a.k.a. Obamacare) makes provision for something called Accountable Care Organizations (ACOs for short).  These organizations are to include enough of the major components of care, both professional and institutional, to allow them to be held accountable for outcomes, safety, and cost, something that has been difficult to do in our traditional provider system. 

The idea of accountability is a good one, but we have yet to figure out how these organizations will be held accountable and by whom. 

A lead editorial in the November 2012 issue of the AARP Bulletin was titled “Let’s Launch a War on Waste.”   It began by pointing out that the importance of hand washing by the providers of health care was first identified some 165 years ago and has been repeatedly confirmed since that time, but, according to a recent study by the highly regarded Institute of Medicine (IOM), something like half of all health professionals still do not follow proper hand washing technique. 

The IOM was further quoted regarding the avalanche of scientific and technological advances, which have stressed “the capabilities of the system to effectively generate and manage knowledge and apply it to regular care” resulting in the waste of some $766 billion per year. 

The editorial concluded by challenging patients to participate actively in their care and to be more observant about what providers do, even to the extent of reminding them to wash their hands.  The implication here is that it is patients who are responsible for holding providers accountable. 

I’m not sure that is enough.  I’m skeptical that providers will be much influenced by patients acting one at a time.   

I had hoped at one time that large employers would take on the role in evaluating provider performance, but they have shown no inclination to do so. 

Government can try, but the need to follow legal processes severely hobbles its effectiveness.

That leaves insurance companies.  The difficulty there is one of persuading subscribers that decisions are being made in their interest rather than in the interest of the insurance company’s stockholders.  Non-profit Blue Cross plans don’t have that problem, at least to the same extent. 

So the question remains.  How are ACO’s to be held accountable and who is to do it?




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