Wednesday, January 14, 2015

ACO: Let's start with organized

Dartmouth's Eliott Fischer once asked whether accountable care organizations would be accountable, caring, and organized.  For this concept to succeed, things are going to have to work a lot better than set forth in a friend's recent note about her elderly parent:

After Mom spent the night in the ER a week ago, I asked the hospital to send the assisted living place the discharge summary (which they had requested, to their credit.)  The hospital said they would when it was dictated.  I got the fax number for them and, of course, it never happened.

So now the assisted living place, which has its own physician, wants to draw her blood tomorrow to do lab work. I mentioned that, when we interviewed this facility, I had been told they had a computer connection to the hospital, and was this not so?

They hemmed and hawed and said, "Yes, maybe."

I said, "Then why don't you look in the computer and get her lab work from the ER visit and then you will have the information you want? "

"Um, well, I guess we could try to do that. "

So then they said, "Are you saying you don't want us to draw her blood tomorrow? "

I said, "Yes, that's what I'm saying. It would be better for everyone if you get the lab work that already exists." (Mom is a difficult stick anyway, by the way.)

It's like the 2 facilities, 3 miles apart, just function in parallel as if the other place doesn't even exist!! It absolutely boggles the mind. And of course they would charge Medicare AGAIN for the lab work-- which, if it had any sense, it wouldn't pay for.

I just sit here and say, it's really, really obvious why health care costs so much here. If you multiply this little stuff by the millions, and remember it includes repeat imaging studies, it really adds up, doesn't it?


Barry Carol said...

I had a similar problem a number of years ago that involved a breakdown in communication between a hospital and my insurer. The insurer wanted to charge me an additional $500 in co-insurance because they didn’t get timely notification from the hospital about my admission because the hospital apparently sent it to the wrong place at the insurer. It could have all been resolved with a simple phone call by the insurer or the hospital.

The problem, I think, is largely cultural. Their attitude is that if the system doesn’t work exactly as it’s should, it’s not our job or our problem to straighten it out. It’s the patient’s problem or the family’s problem. It’s lousy customer or patient service and, in the end, there are usually no adverse consequences except for the patient and family.

Keith said...

I have yet to see any of these assisted care facilities or extended care facilities have but rudimentary types of electronic medical records. The attending physician may have ability to access these records remotely that are generated by the hospital, if he has staff privleges at that institution, but the staff at the assisted care facility may not. While I have seen some movement in transmission of data between different systems and health care organizations, the majority do not allow such easy access to a patients data and health care records. It seems partly due to the competing issues of privacy and how to assure that only the people who need to have access to medical records see this information, while keeping those that don't out.

While we have presumably advanced to the first stage of having hospitals and physicians using electronic medical records, the free exchange of the information is less than ideal. That is probably why your example with the assisting facility staff sounding a little perplexed about whether they are able to access the hospital information is that the personel in the facility may not have this access, but the physician may (or may not if he is not on staff at that hospital). It may be difficult for the staff to be aware of what can or can't be done with patients coming from possibly multiple hospitals as well.

Mitch said...

A great, though sad post. One day data will really be in say 1998 in the real world?:(

Anonymous said...

I have sat in meetings at an ACO network where contract people and the business side people discuss population management and case management to control costs under a global capitated budget. Then I will sit in a hospital meeting (within this same network) where all the management there talk about is more volume and improving the hospital bottom line. Total disconnect even within the networks where top level management is entering into capitated risk deals while hospitals and doctors are looking to do more volume and more work. I think this is why the ACOs have not performed well financially. Add in the lack of member data portability as you point out and it makes it even harder to control costs under a capitated contract.

James said...

When I was working in the system and the government came out with the HIT incentive (requirement) for adoption of electronic health records, i believe it was only the hospitals and physician providers who had access to the funding to make the switch from paper record. Of course the major SNF operators are incentivized for certain electronic capability however assisted living facilities are a completely different and separate entity when it comes to its association with the health-care system, and may very well lack medical incentives to a greater or lesser extent.

nonlocal MD said...

Nobody said assisted living facilities had to have EMR's. The point is that they made no effort to obtain already-existing information rather than stick the patient again because it was easier for them. Similarly, the hospital made zero effort to assure continuity of care by a simple transmission by fax. It has nothing to do with technology, but it has everything to do with lack of patient-centeredness, common sense, any sort of financial accountability, and caring.

Anonymous said...

I agree.

One small correction - the specialty associations are separate from the board certification associations, which is actually a big issue now, since they are pursuing controversial Maintenance of Competence programs and since they are non-membership organizations, it is hard for the profession to influence them. I know you know this - small slip of the keyboard. Personally, I think the board organizations have far overstepped - and are making themselves even richer in the process.

Paul Levy said...

Thanks for the catch!

drbob said...

We have the same issue within our local hospital. I had a recent patient who frequently went to the ER for headaches and got 8 CT scans of the head within 8 months. I have several other patients with similar scenarios. Ridiculous waste of resources.