Showing posts with label Supreme Court. Show all posts
Showing posts with label Supreme Court. Show all posts

Thursday, July 5, 2012

SCOTUS decision irrelevant for health care reform

The decision by the Supreme Court on June 28 regarding the Patient Protection and Affordable Care Act has generated a lot of speculation about the implications for health care reform, the politics of the Supreme Court, the health of Supreme Court justices, and the impact on two party politics. Very few people seem really focused on the issue of health care reform. Even the most positive spin on this decision misses the mark. This article by Brooks that seems to center on the ideology of the Court and how the decision is healing is illustrative with the following quote:

"People in both camps seem to agree: We’ve had a big argument about health care over the past several years, yet we haven’t tackled the big issues. We haven’t tackled the end-of-life issues. We haven’t fixed the medical malpractice system. We are only beginning to correct the antiquated administrative systems."

And:

"... we haven’t addressed the structural perversities that are driving the health care system to bankruptcy. ... American health care is still distorted by the fee-for-service system that rewards quantity over quality and creates a gigantic incentive for inefficiency and waste."

The observations like essentially all observations about the ACA ignore the basic fact that this IS managed care and in fact - managed care on steroids. Managed care has proven time and time again to not contain costs and introduce administrative inefficiency in over two decades of experience. Whether or not the Supreme Court allows it to go forward or it is politically defeated in the future is peripheral to the fact that managed care has not worked as a device to contain health care inflation and it certainly does not provide either quality care or innovation. It can make money for stockholders and CEOs. In fact, in an up or down economy I can't think of a better recipe for making money than being able to deny health care benefits to a group of health care plan subscribers or deny or reduce reimbursement to physicians.

The structural perversity in the system is that in the overwhelming number of cases, personal health care decisions are no longer made between a patient and a physician. Contrary to managed care hype, their decisions are not necessarily based on any legitimate evidence. They are based on what is good for business and in this case we don't have a business that needs to build a better product. We have a business that has to ration access to a service.

Until that is recognized - health care reform is basically continuously rearranging ways to shift money from the people providing the care and the people paying for care to business entities that are "managing" the care.

The outcome is as predictable as where the managed care systems have gotten us to at this point.

George Dawson, MD, DFAPA


Saturday, April 14, 2012

Health Care Complexity, Politicians, and Judges


There is so much wrong with the Affordable Care Act it is difficult to know where to start. According to a recent article in JAMA, I learned that Accountable Care Organizations (ACOs) are charged with improving the quality of care for Medicare patients at less cost. Any psychiatrist in the country who has witnessed the decimation of mental health care justified by that same rhetoric should be skeptical. 

So far the government has been again engaged in a highly coordinated effort to get the ACO initiative up and running. On October 20, 2011 the final rules for ACOs were released and on that same day the Federal Trade Commission and Department of Justice provided guidelines to address the antitrust issues of ACOs.  The JAMA article discusses five major issues related to the creation of ACO's many of which are unrealistic. As an example the antitrust guidelines suggest that ACOs that have a less than 30% market share are "highly unlikely to raise antitrust concerns".  In that landscape, the government expects that ACO's will develop and use quality measures, avoid exclusive relationships with hospitals and specialists, avoid cost shifting via the leverage of large physician groups to private payers, and be monitored to avoid gaming the risk-adjustment scheme. All of these dimensions are highly problematic.

The most problematic aspect of the Affordable Care Act is the same problem that every major piece of legislation in the United States has and that is that nobody reads it. I have seen quotes on how large the actual bill is ranging from 1000 pages to 2700 pages.  I first became aware of the fact that hardly anyone in Congress reads large bills in 2003. At that time I was following the progress of HR 1 (The Medicare Prescription Drug Bill).  I was watching C-SPAN and Sen. Harkin commented that the 1000 page bill was delivered to members of Congress on Thursday morning so that they could debate it on the weekend and vote on Monday morning. He was the first of many senators to acknowledge the fact that nobody would ever read the bill.

At the time I thought that disclosure was astounding. Here we have members of Congress whose full-time job is to design legislation and they are not actually reading and debating a bill that regulates a huge part of the economy and most people's healthcare. I won't even go into the fact that the pharmaceutical lobby was so satisfied with the final result that most of them left town on Friday.

The Affordable Care Act provides us with a new insight into how our government operates. In this case the constitutionality of the bill is also being debated and that was presented to the Supreme Court about two weeks ago. In the Wall Street Journal article it is official that Supreme Court justices are no more likely to read the bill than members of Congress. Justice Scalia is quoted: "You really want us to go through these 2,700 pages? And do you really expect the court to do that? Or do you expect us to give this function to our law clerks?"  We have a check and balance system set up where the check and balance is as defective as the original process.

The overall process here illustrates why it was doomed from the start. The Affordable Care Act is a highly experimental piece of legislation at best. In order for it to function as advertised many unlikely events will need to occur. That would seem obvious to any intelligent person reading the bill but as we have determined there are no members of Congress and no justices in the Supreme Court that will actually do that.

George Dawson, MD, DFAPA


Wall Street Journal. "Complexity is Bad for Your Health" April 8, 2012.

Dawson G.  Medicare Drug Bill #1,  #2,  #3  Three real time posts on my observations on the Medicare Prescription Drug Bill in 2003.


Schleffer RM, Shortell SM, Wilensky GR.  Accountable Care Organizations and Antitrust: Restructuring the Health Care Market.  JAMA. 2012;307(14):1493-1494.