More on accountable care organizations

December 17, 2013

So the Accountable Care Organization returned my call, and pretty promptly at that.  What was explained to me did not make a whole lot of sense, but maybe if I try to explain it, it will make more sense.

While the letter was pretty general about Medicare sharing information from other providers with this provider (the primary care doctor), which made it sound to me like coordination of care and case management, what the person at the ACO told me was that only information from providers who are members of the ACO is shared (with other members of the ACO).  So I asked why route the information through Medicare, why not have the member provider just share the info with the ACO directly?

One answer seemed to be that the information that the provider gives to Medicare may capture different issues, issues that may have gotten left out of the medical records themselves.  (No, putting it into an electronic format does not improve its accuracy or completeness, garbage in, garbage out, and all that.)  It seems that the ACO is providing oversight of the doctor, reminding them of preventive care that is indicated by the billing codes;  to provide a more independent check on the doctor, the information that is used is not reported directly by the doctor to the ACO.

Why the patient isn’t just asked to consent to the doctor sharing information with a supervisor is not clear to me.  I see that the way the written explanation of the sharing is structured would allow for the possibility of Medicare sharing any information they have, including from providers not members of the ACO.  The person I spoke to said they aren’t doing that.  I would say what she said and what the letter said are not completely congruent, and that if the arrangement is not about coordination of care and case management, then I’m not really sure what improvements in efficiency and outcomes they expect.  It sounds as if some of the purpose of this plan may just be to pick up the slack for care doctors’ offices no longer provide, like following up to determine whether there is compliance with care instructions and medication regimens, or following up to see if there is a need for support in order to do those things.

So it sounded as if this is about providing supports to doctors — reminding them of indicated preventive care and providing follow-up with patients.  Apparently doctors’ offices are not themselves positioned or structured to do that.  But adding this intermediate layer, including routing the information through Medicare, sounds expensive to me.  I guess it’s just the cost of doing business when human beings organize themselves into groups with the social and financial incentives we have.

If the ACOs develop into something more robust and effective, then I think we run into the issue of where a patient’s information will end up — then a tiny leak in one place, including in the course of transmission, could mean a whole lot of private information being compromised.  As it is, adding more social workers and such into the mix, in order increase patient compliance, will mean more individuals having access to patient information, including, for example, having the information on laptops they carry into cars to make patient visits.  It will be interesting to see how that all works out.  Visiting nurses already do that, but I’m thinking that multiplying the number of people with access to information increases the likelihood of compromised situations and mistakes.

I think I thought that ACOs would be more like structures located within the offices of the doctors’ practice (not be a separate organization) that would provide checks and would streamline organizational practices, etc., and that the information about patients would not be transferred to new locations or to new organizations.  I guess I am concerned that, like the Affordable Care Act’s exchange website, nobody has really thought through how the whole system will work when all the pieces are put together.

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