Accountable Care Organizations and Medical Professional Liability: What's the Connection?

As attorneys who represent a variety of clients from the medical and insurance industries, we at Gutglass, Erickson, Bonville & Larson find it interesting when a topic surfaces that combines the two.

With the election year being in full swing and health care being one of the main topics, the Patient Protection and Affordable Care Act is being debated at great length. While the details of the act remain a mystery to most of the public, there are a few aspects that have increased awareness regarding patient protection.

Through the PPACA (otherwise known as Obamacare), accountable care organizations (ACOs) are being developed in order to increase the quality of health care services available to patients. Each ACO groups together health care providers including primary care physicians, specialists, nurses and hospitals and gives them a financial budget from which to collectively care for a patient. The goal is to achieve better coordination among the groups and eliminate unnecessary treatments through a more streamlined health care process. If the financial goals are achieved, the savings are shared among the care providers. According to the PPACA, the expectation is that integrating care will increase productivity and decrease expenses leading to favorable outcomes for both the providers and the patients.

While we’ll leave the politics and our opinion aside, we will talk about how this relates to the insurance companies who focus on medical professional liability (MPL). With the ACO structure, health care providers will be integrating their procedures, meaning that MPL policy writers would have to account for changes in the frequency and severity of claims when pricing coverage. If the coordinated care does what it is designed to do, medical errors would decrease and standards of care would increase. One would decrease claims while the other could increase them, and policy writers would have to account for the change in frequency and nature.

There also is the potential for claims from patients to increase due to the number of “non-critial” procedures that will be eliminated through the ACO process. With cost and time savings being the goal, more exploratory tests and exams would be eliminated, which could potentially lead to more claims filed by patients if they are misdiagnosed.

Some industry analysts theorize that as ACOs look to control costs and consolidate efforts, many insurance companies could suffer as niche markets take a backseat by being incorporated into larger programs. Those smaller companies who focus on certain geographical locations also could be at risk as the coverage is rolled into greater policies.

At Gutglass, Erickson, Bonville & Larson, we are experienced in both medical malpractice defense and insurance defense, which is why we find this process particularly interesting. Truly, changes in the industry are taking place, and we need to pay close attention this fall as our nation’s leadership is determined. The result of this presidential election will most likely determine whether or not these trends remain moving forward or are stopped altogether. Either way, it should be interesting.

For now, however, know that we at Gutglass, Erickson, Bonville & Larson will continue to keep providing excellent representation to you whether you are a health care provider, medical insurance professional or any number of our clients in other areas. Our goal is to simply keep doing our job and roll with the laws as they change making sure we know what they are and how to handle them.

For a free case evaluation, call us today!

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