Saturday, July 27, 2013

Obamacare and Accountability: Accountable to Whom?
Accountable 1. Subject to obligation to report, explain, or justify something, responsible, answerable. 2. Capable of being explained.

Definition of accountable

If you’ve kept abreast of the health policy literature, you will have roften un across the word “accountable, ” as in accountable care organizations or accountable prescribing.
If so, you may have asked yourself,  as I have, “Accountable to whom?”
To government payers?
To health plans?
To the Accountable Care Organizations?
To  adherence to protocols, algorithms, guidelines?
To commitment to responsible, evidence-based practice?
To the safest, most effective, and lowest costs for your patient?

So the questions go.  Where the questions  stop, no one knows.  But according to Joseph Kvedar, MD, Director of Connected Health at Partners Health, the ultimate answer may reside in “Guidelines Vs Personalized Health; the Battle for the Future of Healthcare” (The Health Care Blog,  July 25, 2013)
Who and what will prevail? Guidelines from above with algorithm-driven care?  Clinical judgment-driven care?  Personalized health? A combination of each? Decision-making by non-physician clinicians?  The ultimate decision rendered by clinician clinical judgment and instinct based on personalized decisions for personalized patients?
Will decisions be based on evidence from meta-studies of populations? Will these studies be reduced to guidelines?  Will care be standardized and improved by reducing variability? What if guidelines – based on large-scale, randomized coordinated studies – don’t work for individual patients? Which kind of care will be cheaper, safer, and more  effective?
What about personalized medicine? What about tailoring medical treatment to the individual characteristics of each patient?  What about physiological monitoring of each patient,  their mood, their motivation, their activities, their genetics?
Here is Dr. Kvedar’s take on the matter.

1. Personalized medicine, however you define it, is still in the very early stages. We have decades to go, probably on both the genetic and phenotypic fronts, before we can comfortably replace guidelines.
2. We should welcome the sharing of decision-making across the care team and maximize the use of non-physician clinicians. Guidelines give us the state-of-the-art way to do this.
3. The best form of personalized medicine today is still clinician instinct and judgment. This does not mean deferring all clinical decisions to the most senior or most highly trained person on the team. The care delivery culture can be modified to maximize appropriate personalization of care while adhering appropriately to guidelines. This requires an open culture where inquiry is encouraged. Each care team member must be comfortable with what he or she doesn’t know, with spotting exceptions to norms and engaging other team members in a learning dialogue around these exceptions.
Personalized care has as much to do with each patients, each physicians, and the culture in general as management by accountability. Guidelines are based on populations when in reality individual patients are all different and respond differently to the same treatment.  The folks at the Dartmouth Institute of Health Policy and Clinical Practice seem to think that accountable care, more precisely accountable prescribing,  is more effective and more affordable than individual clinicians opinions and actions (Nancy Morden, MD, et al, “Accountable Prescribing” New England Journal of Medicine, July 25, 2013).   Perhaps time will tell where the best quality medicine lies.
How many times the word “accountable”
appears in Obamacare literature is uncountable.
The fundamental idea is simply this:
If only variation we could dismiss,
and have all decisions based on scientific“evidence,”
garnered from studies of population prevalence,
Individual variation would decline,
effectiveness, proper use, and safety would incline.
The word in the ACA is “affordable,”
Translated  means “accountable.”
If only this were so,
individual and personalized judgment
might be no mo,

Tweet:   Obamacare demands clinical “accountability,” a term sometimes at odds with individual judgment and personalized care.



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