Are the Accountable Care Organizations defined in the health insurance reform law something that RA patients need to be concerned with?  On one hand, ACO’s deal with Medicare, so don’t directly affect people who aren’t on Medicare.  On the other hand, anything my doctors spend their time and energy on has the potential to affect the care everyone gets, so we all have a stake in the game.  Any policy on healthcare has the potential to spread to other areas, affecting us all.

Regardless of whether you were for or against the health care reform legislation, the creation of Accountable Care Organizations is one portion of the new law that is particularly puzzling.  Everything I’ve read about it makes me say, “That’s not new.  It sounds like an HMO.”

Instead of acting independently, doctors and hospitals are to form partnerships to oversee patient care, and will spend thousands (millions?) of dollars to jump through all the legal hoops of getting the ACO set up.  New employees will need to be hired to deal with the added workload.  Computerized medical records are a must for Accountable Care Organizations, so every member of the ACO will be required to spend money on EMRs that will talk to one another.  That’s a pretty costly experiment!

In most businesses, people make investments when spending that money means they’ll be able to earn even more money.  Not here.  The goal of ACO’s is to reduce the cost of medical care.  Reducing the cost of medical care means that the hospital/doctor/testing facility will earn less money.  From a financial standpoint, I can’t for the life of me figure out why medical providers would spend massive amounts of money for the privilege of taking a pay cut.

What about on the patient side of the equation?  People who want an HMO have Medicare Advantage; people who don’t want an HMO go with the fee-for-service option.  Now ACOs will take those fee-for-service patients and force them into the renamed HMOs.  Patients may also find that they’ll be seeing less of their doctor, since people seem to believe that in ACO’s doctors will be required to act as administrators overseeing mid-level providers who do the actual patient-care.

Another problem is that patients with health challenges might find it difficult to get a doctor who will care for them.  There are goals – for instance, diabetics should keep their bloodwork in a certain range, people with hypertension also have a target range in which their blood pressure should fall.  One of the reasons that ACOs are required to have an EMR is so that they can send reports to the government on how these patients are doing.   If labs and blood pressure fall within the goals, doctors get a bonus.  If patients aren’t doing as well as the national standards recommend, then no bonus.  Some pay for performance models are even reported to dock physician’s pay when patients don’t meet goals.

Notice that doctors lose pay when patients don’t do as well as desired.  How stupid is that?  Doctors can only diagnose and suggest a treatment plan.  They don’t follow patients home and supervise the exercise regime.  They don’t hand patients their medicines three times a day and watch to make sure the pills are swallowed.  They don’t police their patient’s dinner menus.  It’s the patient’s responsibility to carry out the treatment plan.  It would be much fairer if coverage were restructured so that patients had 100% coverage if all treatment goals are met, but only 80% if they’re only close to the treatment goals, and maybe only 50% coverage if it’s obvious that the patient is making no attempt to live a healthy lifestyle.  Pay doctors fairly for their work, and give the financial rewards/penalties to the patients based on how successfully they implement their treatment plan.

Under this ACO system, doctors will eventually drop patients who aren’t doing well.  Why take $25 to care for someone who isn’t meeting the treatment goals and takes lots of care (time), when it’s possible to be paid $50 for people who don’t need as much care and don’t need to be seen as often?  It’s not that the sicker people will cost less to care for, it’s that they won’t be able to get care at all.

That really scares me.  When doctors can be better compensated for cherry-picking healthy people, instead of taking care of those who truly need medical help, we should all be concerned.


The Mandate

Continued from Anna’s Story.

Fortunately, Anna didn’t need a payment plan.  Her sinus infection responded to the antibiotics and she recovered.  Eventually she found a job with more money and health insurance, and was able to move into a house with heat and hot water.  Anna’s story is no fairy tale, but if it were, it would end “and they lived happily ever after.”

Before you read further, here’s a heads-up.  It’s been a while since I wrote anything about access to healthcare.  I promised to post an ostrich alert any time I do, so that those who don’t want to read about the politics of universal coverage would have fair warning.

The American College of Physicians website includes a blog by Dr. Bob Doherty, and a recent post there, Confusion rules the day, discusses the possible unintended consequences of the recent ruling in Florida about the constitutionality of the Patient Protection and Affordable Care Act (PPACA).  Dr. Doherty closes his post with a question for those who oppose the individual mandate, and asks, without a mandate, how society can get insurance for all.  I responded in the comments section, but another person’s response reminded me of Anna’s story.

The individual mandate would not have helped Anna.  One must have money in order to spend it – a simple economic fact that politicians don’t seem to grasp.  Mandate or no, Anna could not have purchased insurance. 

A mandate is/was unnecessary because Anna did not need insurance.  She needed a doctor.  Think about it; when we send aid to third-world countries, we don’t send boatloads of insurance policies.  We send medicine.  We sponsor doctors and nurses to go work in their professional capacity.  How futile it would be to ship insurance plans to sick people!

Instead of a mandate, our nation needs medical care to be available and affordable.  The mandate does not make medical care available to people.  The mandate does not make medical care affordable.  It just adds expensive layers of bureaucracy to something that doesn’t need to be that complicated.

Insurance does not equal access to medical care.  Every January, my family physician’s office (and likely many more throughout the country) has a sign near the reception desk saying, “We no longer have a contract with xxx insurance company.”  If an insurer won’t pay a reasonable fee, doctors won’t accept that insurance, hence the policy is worthless.  Consider difficulty that seniors have in finding a doctor willing to accept Medicare.  Insurance as we know it now is not the solution.

I’m puzzled as to why the focus is how do we give everyone health insurance?  A more appropriate starting point would be how do we make it possible for patients to see a doctor and get treatment when they need it?  We need to give people better access to medical care without the burden of insurance that costs more than a house payment.

Anna’s Story

Freshly out of college, Anna faced a tough job market.  Her education wasn’t opening any doors for her desired career. She searched and searched, but finally quit being picky about the type of work she’d do and accepted a job with no benefits, paying slightly over minimum wage.

Although she’d been sharing an apartment to keep costs down, when her roommate got married, they young lady needed new living quarters. Fortunately, an apartment was available in an inexpensive part of town – about what it had cost when sharing rent with someone else. Anna had $200 left after paying her monthly rent.   Utilities, food, and transportation quickly devoured every cent.

Bus fare was $1.50 each way, so she had to reserve $3 per day for transportation to get to and from work. Not much, but it added up to $60 a month, and if she didn’t set it aside, it might not be there when needed.  Another $25 for the electric bill meant she had lights in her apartment and a refrigerator that worked.

The first gas bill arrived, and Anna’s jaw dropped at the $187 total. She contacted others in the complex and discovered that everyone else paid $15-$20 per month for their heat and hot water. Armed with this news, a call to the gas company got someone to test the line for leaks, but they found none. Anna matter-of-factly stated that there was obviously a mistake somewhere, but she wasn’t going to argue with them. She didn’t have that kind of money, so they’d better cut off the gas.

Without gas, the kitchen range was useless. Anna found an electric skillet at a thrift store and ate only foods that could be cooked in it. Clean-up meant heating water in that same skillet so she could wash the dishes.

Showers were out of the question; the small bathroom only had a tub. Cold baths in a poorly insulated apartment were fine – even welcome – when it was 90 degrees outside. When winter came, that didn’t work. Sponge-baths using water heated in the electric skillet didn’t suffice. Anna learned that a YWCA membership was $30 a month; it seemed like the best solution to her shower situation.

If you’re keeping track, there was now only $85 left to pay for telephone service, quarters for the laundromat, and a month’s worth of food.  Skipping the phone was tempting, but Anna decided that (given the neighborhood), a telephone might be a good security investment.  Also, she’d never be able to find a better job if potential employers couldn’t call her.  Laundry expenses could be cut if she washed clothes by hand, but the clothes wouldn’t freeze-dry on a line strung across the bathtub.  It took $8 to wash and dry her clothes every week.  There just wasn’t enough money for food.

Searching for solutions, Anna discovered a pizza parlor two blocks from her apartment. When she asked the busy manager if he was hiring, his response was, “When can you start?”

Far from the dreams of a young professional life she’d trained for, Anna left her apartment at 5:30 every morning and rode the bus to the YWCA.  After a nice workout in the pool and some time in the weight room, she enjoyed her hot shower before heading to her 8-5 job.  At 5:00 she was out the door and quickly hopped on a bus. Unable the be two places at once, starting her second job at 5 (as scheduled) was impossible, but the manager understood and let her arrive as soon as she could. After answering phones and making pizzas until midnight, Anna walked home in the dark and stumbled into bed for a few hours of sleep.

Anna was as grateful for the free dinner every night as she was for the extra money.  Minimum wage wasn’t much in those days, but after taxes, the extra job resulted in an extra $70 a week.  It allowed her money for food, and even a bit for new stockings occasionally.  As long as no emergencies came up, she was scraping by.


Eventually, Anna got sick.  Staying home would have meant no paycheck, no food, and ultimately nowhere to live.  She dragged herself to work until the day her boss insisted that she needed a doctor and sent her home.  Anna used the yellow pages to find a doctor’s office near her apartment and explained to the receptionist that she’d been sick for a month and was pretty sure she had a sinus infection.  It was a long shot, but was there any chance of getting an amoxicillin prescription without seeing the doctor?  The receptionist asked why she didn’t just make an appointment, and Anna, near tears, replied that if she did that, she wouldn’t have money to buy medicine.  Silence.

She was put on hold, then the doctor picked up the line and asked questions – history over the phone.  Finally he asked how, out of all the doctors in the city, Anna had chosen him.  “Your office is close enough that I can walk there to pick up a prescription.”

More silence.  “It sounds like you probably do have a sinus infection.  I can’t be positive without examining you, but I’ll prescribe some amoxicillin and we can phone it to the pharmacy.  You don’t need to come here.  If the amoxicillin doesn’t work, though, you need to make an appointment.  We’ll work out a payment plan for you.”

To be continued