Follow the money: How accountable care can detect medical fraud, waste, abuse

Accountable care organizations (ACOs) aim to improve patient care through payment models that reward proactive, coordinated treatments. The ACOs’ ability to dive into patient data can yield another result: detection of patterns that can indicate trends in patient care, including potential waste, fraud and abuse. Accountable for Health CEO Mara McDermott, JD, explains how this comes together.

Medical Economics: You've written about accountable care organizations, ACOs and their ability to prevent and detect fraud, waste and abuse. Can you discuss the procedures or policies in place that facilitate that?

Mara McDermott, JD: Sure, and I think that the case study of success around ACOs and fraud, waste and abuse, really comes back to the reason ACOs were formed in the first place, right? One sort of theory of the case for accountable care organizations is that you could incentivize clinicians and others in the health care ecosystem to find waste and root it out by letting them share in waste reduction. So as we think about kind of the core mission, vision, values of a lot of accountable care organizations, it was looking for fraud, waste and abuse in the traditional Medicare payment system, identifying it, communicating a lot with their partners, whether that's other clinicians or the federal government, to eliminate that waste and then to share in the savings that result from that waste reduction.

Over the last 10 years of advocacy for accountable care, what I have noticed, personally and many others have as well, is that the data capabilities of these organizations has dramatically improved. The data landscape has completely transformed since ACOs came on the scene around 2010 and our ACOs are now super-efficient fraud spotters, right, and waste and abuse. But they are in their data, looking at patient data, population health data, every single day. They are identifying patterns and abnormalities, things that maybe just don't look right for a specific patient, to things that at a population health level are very alarming. We think about these examples in a very wide range. I know we're going to get more into skin substitutes, but we also have ACOs identify, for example, a patient who's a repeat user of the emergency room — oh, I noticed Mrs. Smith has been to the ER every Sunday for four weeks, something else might be going on. To have a case manager who can reach out to Mrs. Smith and find out what's going on. In the case of one of our specific ACOs, what they discovered was that the meal plan that that senior was on was running out by the end of the week. She was, in fact, returning to the hospital as a source of food. Instead, they were able to align her to a community provider of meals, eliminate that hospitalization, a much better outcome for the patient, for the health care system, and obviously, for the Medicare dollar. So we've seen ACOs’ capabilities in this regard across a wide range of behaviors, really improve over the last 10 years, to place where they can be a very reliable partner for the federal government and for patients in terms of making sure that care is right-sized.