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Deane Waldman

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Healthcare Infected With Tapeworms: ACA, ACO, EHB and IPAB

Posted: 03/21/2012 10:49 am

As the Supreme Court takes up the case of the Affordable Care Act (ACA), it is appropriate for me as a doctor to tell them that patient, Healthcare, has a life-threatening parasitic infestation with tapeworms. These are those ugly, evil-looking worms with teeth as in science fiction classic Dune, just smaller. Our healthcare system tapeworms are called ACA, ACO, EHB, IPAB, and NICE.

Washington's recent effort at reform of healthcare has produced the mother tapeworm ACA. ACA protects the bureaucracy, not the patients. It is the antithesis of affordable, penciling out at a cost over $1 trillion. ACA reduces available care, in contrast to what was promised.

What about ACA's tapeworm progeny -- ACO, EHB, and IPAB?

One of the key reasons why our healthcare system does not work is perversity of incentives. The system rewards the very outcomes we don't want. When the system rewards provider performance, providers "perform" too much. The result is that we encourage overspending.

When incentives are tied to spending cuts, as embedded in ACOs (accountable care organization), providers do not do enough. ACOs are perverse tapeworms. They behave like HMOs, insurance companies, and M&M (Medicare and Medicaid) who employ the 3D strategy: deny, defer, and delay. As a result, We the Patients do not get all the care we need when we need it.

ACOs claim they will connect desired patient outcomes to positive incentives. That is nice rhetoric, but that is all it is -- rhetoric.

We the Patients want our healthcare system to provide us with the Vulcan salutation from TV series Star Trek, "Live long and prosper." ACOs do not measure longevity or prosperity (good health), so how can they encourage living long and being healthy?

Finally, ACOs are not "accountable" to the customers or consumers. (I call them We The Patients.) ACOs are accountable to the government, as payer. This means the government -- not the patient and certainly not the doctor -- is in control.

ACOs are tapeworms.

Next comes the EHB (essential health benefits), Federally mandated bundles of health care services. On the surface, EHBs look like just what We The Patients want.

The following are Essential Health Benefits that ACA mandates that insurance companies must provide:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
Regrettably, an EHB is simply tapeworm of a new variety, another scam in the game of
healthcare.

Look at the list above and think like an insurance company or a Medicare adjuster. For both the primary goal is to avoid spending money. Your health and my health are not priorities. Indeed, since health care requires spending money and they are rewarded for not spending money, what will happen? Do you really think that you will get all the "Hospitalization," "Mental health services," or "Laboratory services" that you need when you need them? If you need proof, just look at the waiting lines in Canada.

Next, there are alternative (code for cheaper) therapies, different from what the doctor ordered and not what is best for you. If you need a drug or a procedure, you get the cheapest, not the best.

As a pediatric cardiologist, this author spends hours every day fighting with payers, hours that I would rather spend with patients. Defending my patients has become a major part of my job. "Defending" means bending the rules, sometimes even lying, to get them the care they need, instead of the lowest price care dictated by payers, both private and government (no difference.) Though the law says that payers "can not practice medicine," they do so every day, to the detriment of patients.

A new tapeworm is the IPAB (Independent Payment Advisory Board.) This Board will advise government health agencies such as Medicare and Medicaid on what they should pay for and what they should not. In essence, the IPAB will say what medical treatments are available and which ones are not. Because it is independent and advisory, the IPAB does not come under any Federal rules requiring transparency, public debate, or disclosure.

England has an agency called NICE (National Institute for Clinical Excellence) that has the same responsibility that IPAB has in the U.S. Thus, we can see what actually happens using this approach.

The result has been, predictably, population-based guidelines rather than the best interests of individual patients. For example, when NICE determined that kidney dialysis after 55 years of age and heart surgery after 65 were not cost-effective, they were not approved, not paid for, and therefore not available. So, if you live in Great Britain and are 56 with kidney failure or 66 with heart failure, you just... die.

Since IPAB was built with the same thinking and for the same purpose as NICE, you can expect the same results. Is that what the Americans want or expect, or were promised?!

ACA, ACO, EHB, and IPAB are tapeworms that are consuming healthcare. They make the system even more out of touch with patient needs and wants. They make the incentives even more perverse (if that is possible.) These tapeworms are healthcare exacerbation -- the opposite of what they are called, reform.

 

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