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How one man unintentionally overdosed every day on blood thinners

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Half of heart disease patients don’t take their medications as recommended. As a result, they end up in the hospital more often. Yet a recent study of cardiologists found most didn’t know if their patients are taking the medicines they prescribed to help prevent heart problems. Most said they don’t ask if patients are taking their medications, even though the doctors know how important it is.

A new form of health plans, called accountable care organizations (ACOs), are bridging the communication gap between doctors and their patients. ACOs are integrated networks of hospitals, doctor’s offices and other health care facilities that get paid by an insurer based on the quality and efficiency of care their patients receive – not how many visits, tests, surgeries and hospital stays they bill. Working together with the insurer, they can have access to information about an ACO patient’s care.

That means the doctor has more information at his or her fingertips when the patient visits. Has the patient been filling his prescriptions regularly? What were the results of the most recent tests he had? What other doctors have seen him, and what treatment or recommendation came from that visit?

Where it’s working

Leaders from two organizations offering ACOs in cooperation with Aetna talked about the advantages of ACO arrangements at a recent bswift conference.

“Too often doctors don’t know what’s going on with the patient at other doctors or hospitals. The insurer knows,” said Dan Styf, senior vice president at Memorial Hermann Health System and CEO of the Memorial Hermann Health Plan in Houston. “Data from claims gives us perspective, so when the patient is sick and shows up in the system, we can see what is happening and take action.”

Three different doctors unknowingly prescribed blood thinners to the same patient. As a result, the patient was unintentionally overdosing on blood thinners… every day.

At Advocate Physician Partners in Chicago, the patient record system showed a man with a heart condition was already a “frequent flyer” in his local Advocate emergency room. A care manager called the patient to see if she could help.

According to Scott Kent, vice president of Field Operations for Advocate Physician Partners, the care manager found the patient was already being seen by two other doctors outside the ACO. None of them knew about the other doctors, so all three doctors had prescribed blood thinners. The patient’s unintentional daily overdose was sending him to the ER.

ACOs growing across the country

Established with private insurers or as part of a Medicare or Medicaid program, existing ACOs are growing and new ACOs are starting up; they are now in 49 states and the District of Columbia (the only state without one today is North Dakota). The federal government alone has almost 500 ACO arrangements for Medicare and Medicaid recipients, and many private insurers are entering into ACO arrangements at a similar pace. Aetna, for example, is on track to have 75 percent of its payments in value-based care arrangements, including ACOs, by 2020.

Under these value-based arrangements, the health systems are paid based on the quality and efficiency of care their patients receive. Many of the quality measures are related to the effective use of medications. That means ACOs put particular focus on making sure patients are on the right medications and are taking them as directed.

ACOs put particular focus on making sure patients are on the right medications and are taking them as directed.

Some health plans are built around an ACO. For example, Aetna and bswift, the Aetna company that offers private exchange and benefit administration capabilities to employers, brokers and other organizations, offer ACO-based plans to employers and individuals in many areas of the country.

People who belong to other plans and choose a doctor or hospital that is part of an ACO network may also get the benefits of the arrangement, and not even know it. Those benefits include improved quality measures, shorter hospital stays, fewer readmissions and increased use of generic drugs – all of which mean the patient can spend less on health care.