A more realistic approach to achieving accountable care

Hospitals that are already struggling financially to stay afloat face significant challenges in the coming months and years under some of the provisions of Obamacare.

Under the Affordable Care Act’s Hospital Readmissions Reduction Program, hospitals that readmit certain patients within 30 days of discharge could face significant penalties.

The question is whether hospitals really have that much control over factors leading to readmission and whether they are really at fault.

Some readmissions are unavoidable, especially in patients who are elderly, poorly educated, and noncompliant. Many of the contributing factors to readmission in these scenarios are not necessarily attributable to a lack of poor care during the hospital stay, but rather to a number of care-coordination or compliance issues that involve the patient and/or the doctor subsequent to discharge.

The initial penalties, which took effect several months ago, were only for people readmitted for heart failure, myocardial infarction, or pneumonia. The list has now been extended to include those patients who may be readmitted following hip and knee replacements.

The unintended consequences of these reimbursement policies could ultimately impact the quality of care patients receive as hospitals will be reluctant to readmit for fear of incurring penalties.

The policies also put many academic hospitals and tertiary care centers at a disadvantage. These facilities often care for patients who are sicker, and it is the sicker population that may very well be prone to readmissions.

A key issue to reducing hospital readmissions in any scenario requires well-coordinated care. In fact, the framework of accountable care organizations has been designed to improve efficiencies in care delivery by providing incentives for a group of physicians caring for a patient.

The logic is, of course, that if there is a single bundled payment in which all doctors involved in the patient’s care will share, it will force greater efficiencies in delivery of that care.

In an ideal world this, in fact, may be the case, but achieving this utopia will be challenged by the lack of adequate information to enable hospitals, patients, doctors, and other care coordinators to effectively communicate and ensure that information doesn’t fall through the cracks.

A more realistic approach to achieving accountable care would have been to provide the necessary resources to ensure that every stakeholder, in fact, has the necessary tools and technology to enforce and measure coordination of care and quality. Although we have taken some early steps in the right direction, it may be premature to impose penalties on a system that is ill-equipped to deliver what’s being asked.

Sreedhar Potarazu is an ophthalmologist and founder and CEO of Vital Spring Technologies. He blogs at Business and Policy.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Accountable care is probably an incorrect phrase. Accountable pricing may be better.
    This entire punishment scheme is based on the incorrect premise that we have too many admissions, which we don’t. We actually have less hospitalizations than most developed countries. Our expenditures are higher because the cost of each admission is inordinately higher than in other countries. So instead of addressing the root cause of pricing failure, we decide to ration hospital care, starting with readmissions, since these fit well with the mythology of lousy care and “broken” systems..

    After all, everybody knows that if you have to take your car back to the mechanic within 30 days of having it fixed, the mechanic didn’t do a good job to start with. And hospitals are like mechanics, and we are all like cars. The latter is becoming increasingly true, so maybe this will work. Most likely though, hospitals will find ways to circumvent the definition of “readmission” and/or further raise prices for everything to account for the “warranties” they are forced to issue.

  • Guest

    “The unintended consequences of these reimbursement policies could
    ultimately impact the quality of care patients receive as hospitals will
    be reluctant to readmit for fear of incurring penalties.”

    ========================================

    This is a real worry.

  • Dr. Drake Ramoray

    “A more realistic approach to achieving accountable care would have been to provide the necessary resources to ensure that every stakeholder, in fact, has the necessary tools and technology to enforce and measure coordination of care and quality.”
    ============================================

    You want more than the facility fees you are already getting…. Really!? I’m speechless.

    • http://www.twitter.com/alicearobertson Alice Robertson

      I should upload my bills and see the facility fees. I was billed $500 for a very large splinter removed by a surgeon which I understood. But I didn’t understand the facility fee of $250. I was at the new facility the Clinic built for probably less than an hour total. It’s usually about $72 for a basic office visit, right on up from there. So with a $50 co pay and facility fee even someone with insurance can pay $122 to be seen for a sore throat. I realize the reimbursal rate is only about $60 for that visit, but that’s still almost $200 for an inane visit.

  • Guest

    “Accountable Care”? What is this “Accountable Care”? Is this what we’re calling Obama’s healthcare reforms now that 9 out of 10 Americans start sniggering uncontrollably when they hear them referred to as “Affordable Care”?

    #EvolvingNomenclature

  • http://euonymous.wordpress.com euonymous

    You mean “Romneycare”?

  • charles_beauchamp

    “Accountable Pricing” is a good term.

    Is it “accountable pricing” if the hospital lab charges 500 dollars for a urine culture done on an outpatient, versus the ~20 dollar charge by LabCorp for doing that same test out of a private practice doctor’s office?

    For outpatient lab tests, it is possible to make the argument that “facility fees” drive up costs 10 fold or more than costs of the same tests done in a private practice office setting that uses LabCorp.

    The “500 hundred dollar urine culture” is a real example of pricing way beyond the value of the test, especially in comparison to the prices of the “competition”.

    There is absolutely no excuse for pricing outpatient labs at a level that should be beyond the pale, even if the patient was in the intensive care unit.

    • http://www.twitter.com/alicearobertson Alice Robertson

      You are right, but I wondered about this type of scenario (I had an interesting call yesterday from a private contractor of my insurer asking me to get my MRI at another imaging place that was only $350 compared to Cleveland Clinic’s price of $2200. They were quick to call because I had just minutes before received the call that the MRI was approved by the insurer). She said it could save me money on my co-pay and that they were trying to drive down costs of testing so insurance premiums could be driven down (she even offered to make me an appointment with a closer imaging place. I was in too much pain to wait the extra time but will consider this if there is a next time). I am curious as to why my insurer is paying Cleveland Clinic more than the $350 other imaging places are receiving in reimbursement rates (knowing w/o insurance the patient would definitely serve their wallet well to make the cheaper appointment).

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