It has exceptionally rare to meet a healthcare professional who didn’t feel responsible – or accountable, for their patient. Passage of the healthcare reform act has moved the phrase “accountability” to the forefront; the Accountable Care Act final regulations from CMS has exacerbated this discourse and elevated confusion between accountable care and an accountable care organization.
ac·count·abil·i·ty. noun \ə-ˌkau̇n-tə-ˈbi-lə-tē\. ..the quality or state of tə-ˈbi-lə-tē\. ..the quality or state of being accountable; especially : an obligation or willingness to accept responsibility or to account for one’s actions <public officials lacking accountability. (Source: http://www.merriam-webster.com/dictionary/accountability)
Accountability appears destined to travel the same journey as HIPPA. Current HIPPA regulations barely resemble its intent — protection and security of personal health information. The last time I went to my physician and pharmacy, after signing countless HIPPA forms, I “signed in” by writing my name on a clipboard. In plain sight were the names of everyone who had been in the office or picked up a script before me on that day. Where was the privacy and protection?
Quality of care, efficiency, and cost containment is the rationale for increased accountability of care. Laudable (and necessary) goals are the underpinning of regulatory and legislative reform that emphasizes greater coordination, integration, and alignment of care delivery. Building a medical home, integrating electronic health information, and aligning physicians, payers, hospitals have saturated industry discourse. The final regulations for CMS Shared Savings Program and accountable care organizations in October flooded industry chatter, C-suite agendas, and even blog sites.
One on one dialogue with colleagues indicates the journey is grounded with a strong belief the result of integration, shared knowledge, and coordination is a solution for industry ills. The barriers – real and perceived, are mammoth. The information technology and operational realignment required to support the discourse are financially impossible and resource improbable.
This is not advocating abandoning the vision of accountability. It is a plea for a reality check. The ACO comment period recently concluded evidenced the investment – resource, financial, human, technology, concerns of healthcare enterprises. If the decision on the board room table is to apply for ACO or a decision to employ the full medical staff, leadership and governance may not be taking into consideration the need to build a foundation that supports these new structures. Transformational change is not akin to a joint replacement. The organizational transformation envisioned requires operational and cultural investment, clearly defined strategic vision, and informed resource investment within an abbreviated timeline.
Operationally, accountable care becomes action through a medical home model, value based purchasing, bundled pricing, accountable care organization, and other programs, processes, and models that create linkage from one provider to the next, one site of care to the next. Any consumer or provider is quick to point out the need and relative value or increased sharing between care givers and sites of care. Decades of specialization and sub-specialization have resulted in greater life saving efforts. Concurrently, the ability to retain the knowledge and rationale from one healthcare decision to the next is virtually impossible.
The need for technology solutions that parallel accountability of care are at the forefront of resource requests, investments, and staff focus. Standardization and extensible data models allows the gap between our current and future state lessen – most often the barrier is the ability to provide sufficient capital to fund these investments.
The cultural change required supersedes the financial investment. A lesson learned from the HIPPA journey is that inherently we do not like to share information. Under the veil of confidentiality, the notion of sharing outcomes, decision making, or clinical indicators is guarded. When the information is shared, the barrage of questions regarding integrity, standardization, and decision making input occurs.
Case in point – prior to knee replacement, an MRI was conducted. The results of the MRI could not be sent directly to the patient. Results were to go to the primary care physician and ordering physician; not to the patient. The cost of the MRI was borne by the patient, the MRI was of the patient, and the results impacted the health of the patient. Obtaining the results (including a copy of the scan) was at the discretion of the ordering physician.
The cultural change required to adapt to greater accountability in care must be industry-wide. It is improbable that greater accountability can occur unless the system is completely transparent. Pilot programs or unique sub-sets of the care delivery system are insufficient to build the integration and responsibility required.
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