Accountable Care Organizations

As a part of healthcare reform there has been a lot of talk about the creation of Accountable Care Organizations, but what exactly are they, why are they so controversial, and what is their potential impact on the delivery of Emergency Medicine? 

Under the Affordable Care Act, ACOs have been created as a new payment model under Medicare.  There are also have pilot programs to extend the payment model to Medicaid and private insurance.  The goal of ACOs is to create a hospital and provider network that would provide care with quality and cost saving initiatives and CMS and the providers would share the cost savings.  The goal is to provide high quality care with reduced cost using a more integrated delivery approach and more aggressive quality monitoring.

ACOs may have some conflict with the traditional practice of Emergency Medicine in several ways.  First, physicians will become employees of ACOs.  Traditional Emergency Medicine doctors have the choice in some states to work as independent contractors.  Being an independent contractor allows them to provide access to care without a conflict of interest and without outside influence. 

ACOs may also conflict with laws in some states that prohibit the corporate practice of medicine. The CPM laws prohibit a hospital (or non-physician entity from directly hiring physicians).  CPM laws are designed to protect the physician patient relationship from conflict of interest, allowing doctors to be hired as independent contractors and to do what is best for the patient without undue influence. 

Although ACOs goals ares to to provide high quality integrated care at a lower cost, we will have to wait and watch closely to see what the overall effect truly will be.

New Affordable Care Act Tools Offer Incentives for Providers to Work Together When Caring for People with Medicare (October 20, 2011)   http://www.healthcare.gov/news/factsheets/2011/10/accountable-care10202011a.html

Fisher ES, Shortell SM (2010). Accountable Care Organizations: Accountable for What, to Whom, and How. JAMA 304 (15): 1715–1716.

Pre-Existing Condition Insurance Program (PCIP)

          As a physician, one of the things that frustrates me is when people are denied health insurance or are forced to pay extremely high premiums because they have a "pre-existing" medical condition.  Now, as a part of the Affordable Care Act, children and adults that have a preexisting medical condition and have been without health insurance for the past 6 months are eligible for insurance through the Pre-Existing Condition Insurance Plan (PCIP). 

          In order to be eligible for the PCIP, one must be a US citizen, or be residing in the US legally.  The individual also needs to provide a letter from a physician stating that they currently have a medical condition, disability or illness or that they had one within the past 12 months.  So far over 35,000 people have enrolled in the PCIP.

          This is a transitional program that will be available until 2014.  After 2014, people with pre-existing conditions will be eligible for health insurance through insurance exchanges.  Also after 2014 it will be illegal for insurance companies to deny people health insurance coverage or charge higher premiums because they have a pre-existing condition. 

More information on this topic can be found at these links:

Pre-existing Condition Insurance Plan.  https://www.pcip.gov/

Health System Reform Insight, Federal insurance plan provides coverage for pre-existing Conditions (August 25, 2011), https://exchweb.bcm.tmc.edu/owa/redir.aspx?C=c744625626ce42d0931a6030547d7e8e&URL=http%3a%2f%2fwww.ama-assn.org%2fama%2fpub%2fnews%2fnewsletters-journals%2fhsr-insight-archive%2faugust-2011%2f25aug2011.page

In Addition to Bath Salt Drugs Being Illegal, the DEA now has made the Synthetic Stimulants Used to Make the Bath Salt Drugs Illegal As Well

Last Month I wrote about Bath Salt drugs being made illegal by the DEA (see a copy of that blog post below).  Now the DEA is taking it one step further and specifically banning the three synthetic stimulants Mephedrone, 3,4 methylenedioxypyrovalerone (MDPV) and Methylone that are used to make Bath Salt drugs.  The DEA used its emergency scheduling authority to control the three synthetic stimulants making possessing and selling these chemicals, or the products that contain them, illegal in the United States.  More information can be found at this link:  Chemicals Used as "Bath Salts"  Now Under Federal Control and Regulation, http://www.justice.gov/dea/pubs/pressrel/pr102111.html. My Original Blog Post: Patients in Emergency Departments across the country have been presenting with overdoses of a fairly new drug called “Bath Salts” (psychoactive bath salts).  Bath salt drugs actually have nothing to do with the chemicals that you may use in your bath, they are actually synthetic drugs  (methylenedioxypyrovalerone,  mephedrone and methylone).  These chemicals inhibit norepinephrine–dopamine reuptake and act as central nervous system stimulant.  According to the New England Journal of Medicine, these drugs can cause extreme sympathetic stimulation and profoundly altered mental status. “The sympathetic effects may include tachycardia, hypertension, hyperthermia, and seizures, and deaths have been reported. Altered mental status presents as severe panic attacks, agitation, paranoia, hallucinations, and violent behavior (e.g., self-mutilation, suicide attempts, and homicidal activity).”Bath salts were legal until recently when the DEA made them illegal. As of September 7, 2011, possessing and selling these chemicals or the products that contain them are both illegal in the United States for at least 1 year while the DEA and the US Department of Health and Human Service gathers more information.  The DEA is using its emergency scheduling authority to temporarily control bath salt drugs.   More information about this new law and about bath salts can be found at these links:http://www.medscape.com/viewarticle/749304http://www.nejm.org/doi/full/10.1056/NEJMc1107097

Physicians May Violate HIPAA by Using Mobile Devices to Communicate with Patients

Many doctors use their mobile devices (Blackberry's, iPhones, etc) to communicate with patients.  However, you should be aware that using these devices to exchange protected health information (PHI) is covered by HIPAA.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law that was enacted to establish  national standards for electronic health care transactions and also address the security and privacy of health data.  Hospitals, medical offices, medical providers, HMOs and health care clearinghouses may only use or disclose protected health information (PHI) for treatment, payment and health care operations.  Users of these devices to share protected health information must have specific administrative, physical and technical safeguards (e.g., encryption) in place to protect patient privacy.

More information on this issue can be found at the links below:

The Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).  http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

Healthcare Providers May Violate HIPAA by Using Mobile Devices to Communicate with Patients, ABA Health eSource (October 2011) http://www.americanbar.org/content/newsletter/publications/aba_health_esource_home/aba_health_law_esource_1110_barrett.html

Hospital Liable for Assault of one Patient by Another Patient Under the Doctrine of Premise Negligence

A court in Tennessee recently held that a hospital can be held liable for patient safety, not under the doctrine of medical negligence, but under general premise liability, i.e., failure to keep the environment safe for a patient.  This ruling comes from a 2010 case in which a woman who was admitted to a psychiatric unit for hallucinations was assaulted in the shower by a male patient.  The court held that the facility did not have appropriate safeguards in place to protect their patients from assault.

The bottom line, hospitals and medical professionals are responsible for keeping their patients safe. 

More information on this topic can be found on the amednews website: Hospital can be sued in man's alleged attack on another patient.

http://www.ama-assn.org/amednews/2011/08/29/prca0829.htm.