Saturday, November 13, 2010

What does the Border have to do with Accountability?


as Posted on The Health Care Blog

Does This ACO Thing Really Mean We Need to be ‘Accountable’?


Kuratis Last month The American College of Physicians (ACP) released a well-reasoned and thorough position paper, The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practicesalt.

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

At this time, implementation of the above principles within care coordination agreements represents an aspiration goal…

The care coordination agreements should be viewed solely as a means of specifying a set of expected working procedures agreed upon by the collaborating practices toward the goals of improved communication and care coordination — they are not legally enforceable agreements between the practices. [emphasis of “solely” is in the original document, not added]


Don’t expect to hold us accountable….and don’t expect to be able to sue us if we don’t get it right

Virtual Immigration Fence Failure – A Lesson for Medicine?  from Medical Innovation Blog

imageRichard Reece, M.D.

As Americans, we believe “virtual surveillance” techniques, drones over Pakistan, orbiting spy satellites, cameras on street corners and in stores, telemonitoring of patients with chronic disease with implanted sensors, e-ordering systems to control utilization of high tech medical technologies, virtual integration of doctors and hospitals to reduce care fragmentation – will make us more secure and healthier.
This may be, but we need to understand better what’s taking place on both sides of the technology fence.
The Techno sphere Versus Boots on the Ground
Technologies, no matter how sophisticated, can never replace boots on the ground, humans on the frontlines, police on the streets, or the human needs of populations you are trying to deflect, defeat, control, or serve.
The Virtual Arizona Fence
The “virtual failure” of the “virtual fence” on the Arizona border is the latest example of surveillance technology limits. This “invisible” fence, consisting of strategically and periodically placed high tech radar towers equipped with state-of-the-art monitoring gadgets has failed to stem the tide of immigration. Where there’s a will, there’s a way around the fence.
After 4 years of effort, construction of 50 miles of fence over the 2000 mile Mexico-US border, and a $1 billion contract with Boeing, the Obama administration is abandoning the fence.
High winds, tumbling tumbleweeds, weak cameras, slow software, blurry images that confuse cars with humans, and determined immigrants in search of a better life have combined to circumvent the fence.
In the words of a New York Times editorial,
“The ‘virtual fence’ was a misbegotten idea from the start, based on the faulty premise that controlling immigration is as simple as closing the border — and that closing the border is a simple matter of more sensors, more fencing and more boots on the ground. So long as there is a demand for cheap labor, a hunger for better jobs here, and almost no legal way to get in, people will keep finding ways around any fence, virtual or not.”

The Lesson

For information technology enthusiasts and for those who monitor patient health behaviors through web-based “consumer empowerment” techniques or “physician improvement” technologies, there is a lesson to be learned here.
You cannot control human behaviors at the level of patient-doctor interactions no matter how “sophisticated” your data mining or monitoring efforts. And you cannot do it without more “boots on the ground,” more physicians in the clinical trenches to critically appraise human needs, to prevent “immigration” towards bad health and high cost hospitalizations.  (underline mine) High tech fences will not keep immigrants out of the human garden. And you cannot weed the garden using high tech information sensors.

Posted by Richard L. Reece, MD at 12:24 PM

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