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ACA – A radical restructuring of health care

The various provisions of the ACA are kicking in and I am alarmed at what I see as serious design flaws that in the name of cost cutting will radically change the nature of the practice of medicine. I am posting my observations and some links to the professional journals etc. with examples of recommendations and policies. I have no doubt this is leading and will lead to significant suffering and deaths because of inevitable cuts in benefits made available to the public, especially those available for the sicker and older patients unless some of the provisions are undone.

This process  of deterioration in care will be the result of primarily two things written into the ACA. First; the law “mandates a national comparative outcomes research project agenda. ….. Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” —–   http://www.ncbi.nlm.nih.gov/pubmed/21860057 .

The second provision that will profoundly influence treatment decisions is inclusion of provider monetary incentives and dis-incentives. This in essence is setting fees higher for physicians who treat less than those who treat more.

I am working on finding a better framing for communicating in more understandable language facts and concerns and will keep at it here on this site.In effect the aim is to ration care and place the responsibility for the means of cost cutting on the physician. This to be accomplished by adding a cost or “greater good” parameter to the Hippocratic tradition of physician as exclusively serving the best interests of patients (even beyond the interests of the physician him/herself). The Times report describes this with the greater clarity and I am reposting a link to it.

http://www.nytimes.com/2014/04/18/business/treatment-cost-could-influence-doctors-advice.html

The several pressures placed on the physician by the ACA creates a situation of divided loyalties to a degree I find unacceptable.  I see it as truly changing 4000 years in very disturbing ways. Instead of being faithful to the mandates of Hippocratic ethic physicians planning what treatment will be offered to their patients, physicians are placed in the position of determining what has highest priority, most effective in preserving life and relief of suffering?  or  by limiting treatment options serving a “greater good?”  This to be defined as economic burden on an ill defined entity; These considerations while worrying about his/her income security.  Fortunately there is some stirring in the profession to question, if not protest.  I urge the public to inform themselves and support any protest efforts.

The quoted definition of the ACA mandated entities determining best “evidence based treatment guidelines”  sound solid  and  scientific.  They are in fact not doing research following scientific method. They are in greater part simply doing reviews of published material  (reading) and applying statistical analysis to make their determination. They do not pretend to always be able to determine consequences when recommending cessation or decrease in services. The radical decrease in breast cancer screening and treatment  now being proposed is an example in which the authors of published reports admit that they cannot prove that lives will not  be lost. There is no doubt that suffering will be increased.  They casually say a later diagnosis is no problem because we now have effective chemotherapy.

Today’s JAMA has two revealing reports of just how it is visualized physicians will be determining treatment. The full articles are behind a pay wall but there is sufficient available free to understand and appreciate the documentation for my observations. I can arrange for full copies for special circumstances however for anyone wanting details.

The first is explicit. In just how this cost consideration is incorporated.

http://jama.jamanetwork.com/article.aspx?articleID=1861810&utm_source=Silverchair%20Information %20Systems&utm_medium=email&utm_campaign=MASTER%3AJAMALatestIssueTOCNotification04%2F22%2F2014

This second is actually presenting another cost saving change in a thousands of years practice, that of not requiring explicit permission to give life saving emergency treatment to a patient unconscious, or otherwise unable to communicate.  But I included it to give some idea of just how the thinking is going.

http://jama.jamanetwork.com/article.aspx?articleID=1861784&utm_source=Silverchair%20Information %20Systems&utm_medium=email&utm_campaign=MASTER%3AJAMALatestIssueTOCNotification04%2F22%2F2014

I am trained in pediatrics, pediatric oncology, psychiatry and child psychiatry.These observations and interpretations I make as a physician who has over some 40 years done clinical research as an NCI principle investigator with special training in ethics or experimental treatments; taught medical students as a member of the faculty of a large medical school; and served as specialist and delivering primary bed side medical care.