Early Analysis ......More to Come

An Act of Congress?  More Like Multiple Acts of Insanity. - Part I

We have all heard about how it takes an "act of Congress" to make major changes.  Well the Senator Reid's so called "Patient Protection and Affordable Care Act" is more like an act of medical, fiscal and Congressional Insanity than a solution to any problem. The underlying theme of the bill, as in the House bill, is to grant broad and inappropriate powers to the government to define medical quality and create a cost-control regime directly intended to cut spending on needed medical care. 

The worst aspect is that it creates a system of penalties for doctors who go over-budget and seeks to redefine the profession of medicine to one designed, managed and approved by bureaucrats and government agents.  A read-through the bill brings to mind more appropriate names for this "Act of Congress" for the hundreds of sections in this 2075 page bill that will force Americans to buy higher priced insurance and tax the economy into submission. All while placing an unsustainable economic burden on future taxpayers and our children that will grow far beyond the government's frequently inaccurate spending forecasts.  So what kinds of Acts are more appropriate titles for the sections in this bill?

Promote the Secretary to Monarch Act. Throughout the Bill the Secretary of the Department of Health and Human Services (HHS) is granted broad new powers that are completely outside of congressional oversight. The Secretary: determines quality; determines appropriate budgets for patient care; determines physician payment; penalties and incentives; determines who is eligible for key programs; determines what groups of doctors patients will see; determines where physicians can practice to avoid a penalty and more; requires reports from physicians. The term "secretary"

Big Brother Is Watching Your Doctor Act.  Section 5404, p 1430 ^[i]A Primary Care Extension program will send government agents to physician practices to supervise doctors reporting to the government of compliance with performance measurements.  "Clinicians" can be primary care providers and are not necessarily required to be physicians. There will be an effort to disseminate "new knowledge" to ensure evidence based practices.  For instance, on insuring that only women over 50 get mammograms!

Redfine Nurses as Doctors Act - Remove Constitutional Rights act' Section5501, page 1440 Redefines nurses, physician assistants and clinical nurse specialists as "Primary Care Providers".  From 2011-2016- Provides a 10% "incentive" for  "primary Care services" ; Prevents administrative or Judicial Review on disputes (denies constitutional due process rights of "providers");

"Practice Surgery Where you are Told" Act.  Sect 5501(b), page 1443: If you practice general surgery in an "underserved" area (defined by government - the Sec. of HHS), receive  an "incentive" from 2011-2016.  Be Penalized 10% for practicing surgery in an area that is not "underserved" - and lose "incentive" after 5 years and hopefully have a practice that can be sustained when incentive is gone.   

Saving Money off of Children's Medical Care Act: Section 2706, page546:  The Secretary of HHS is granted more power to arbitrarily cut costs for medical care, but for children's health care.  Pediatricians would be organized into "Accountable Care organizations" and given "incentives" (payments) if they achieve "minimal savings" established "by the state".  Such incentives will be directly proportional to the amount of money saved for "the state" but there will be a cap for incentives that will limit payments to physicians.  

Penalize Doctors for Going "over-budget" Act:  Section 3022, page 739; In the "Medicare Shared Savings" sections, doctors are pressured into "accountable Care organizations" - Accountable to the Secretary, HHS. Secretary given broad new powers to define "quality" and "Efficiency" and determine appropriate "utilization" of hospitalization and ambulatory care conditions.  Equivalent to the capitation model that was widely rejected under managed care in the '90's.  ACO must have primary care providers and cover at least 5,000 Medicare beneficiaries for three years.  Will Only receive a bonus (avoid a penalty) if meet the spending cut "benchmark" established by the Secretary.  Does not provide for new funds for bonuses but rewards "incentives" only based on actual savings to Medicare that will occur by denying care to patients. (VIOLATES AMA PRINCIPLES ON PAY FOR PERFORMANCE RELATING TO VOLUNTARY PARTICIAPTION, AVOIDING ECONOMIC UNDERMINING OF NON PARTICIPATING PHYSICIANS AND FAILURE TO PROVIDE NEW FUNDS FOR INCENTIVES).

Tie the doctor's hands and deny their judicial rights act part II. Section 3022, page 750 Will Penalize a doctor who avoids a "high risk" patient to ensure costs are kept low. (The "Tie the Doctor's Hands Act").  There shall be no appeal rights to any administrative law judge or court for decision on payment or quality made by "the Secretary"

Patient- Go See the Doctor you are Told Act  Section 3022, page 745 ^[ii]"The Secretary" will decide which doctors a patients (a "Medicare Feee For Service Beneficiary") will see by making sure they go to the ones that save the most money for the government.  Only those doctors saving the most money for the government will get the highest payments to themselves.

Put 'em all on a Budget and make 'em Fight for payment Act  Section 3023, pg 751-  "The Secretary" would "BUNDLE" all payments for an "Episode" of care to Hospitals, Doctors, Nursing Homes, and "other Services" (defined by Secretary) for up to eight conditions also defined by the Secretary.  Each group would have to fight among themselves for payment with doctors usually at the mercy of hospitals. Patients will lose as each group engages in a race to the bottom to deliver the cheapest possible care often by denying services to patients so they can find a way to get paid. In other words for a condition (like a heart attack), all the money is in one basket for a patient and each group must jealously guard their share and will get a bonus if they spend less on the patients. Their will be a "bidding" process to the Secretary that will result in a "low bid" mentality for patient care. Good luck Patient for any care you need 3 days prior and 30 days after hospitalization (or longer if the Secretary says so).

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 Section 5404, Page 1430

1    ''(2) PURPOSE.-The Primary Care Extension

2     Program shall provide support and assistance to pri

3     mary care providers to educate providers about pre

4     ventive medicine, health promotion, chronic disease

5     management, mental and behavioral health services

6     (including substance abuse prevention and treatment

7     services), and evidence-based and evidence-informed

8     therapies and techniques, in order to enable pro

9     viders to incorporate such matters into their practice

10    and to improve community health by working with

11    community-based health connectors (referred to in

12    this section as 'Health Extension Agents').

13    ''(3) DEFINITIONS.-In this section:

14    ''(A) HEALTH EXTENSION AGENT.-The

15    term 'Health Extension Agent' means any local,

16    community-based health worker who facilitates

17    and provides assistance to primary care prac

18    tices by implementing quality improvement or

19    system redesign, incorporating the principles of

20    the patient-centered medical home to provide

21    high-quality, effective, efficient, and safe pri

22    mary care and to provide guidance to patients

23    in culturally and linguistically appropriate ways,

24    and linking practices to diverse health system

25    resources.

page 1433

O:\KER\KER09924.xml [file 5 of 9] S.L.C.

1     ''(B) PRIMARY CARE PROVIDER.-The

2     term 'primary care provider' means a clinician

3     who provides integrated, accessible health care

4     services and who is accountable for addressing

5     a large majority of personal health care needs,

6     including providing preventive and health pro

7     motion services for men, women, and children

8     of all ages, developing a sustained partnership

9     with patients, and practicing in the context of

10   family and community, as recognized by a State

11   licensing or regulatory authority, unless other

12   wise specified in this section.

Primary Care Extension Agencies established by a Hub

13     under paragraph (1) shall-

14     ''(i) assist primary care providers to

15     implement a patient-centered medical home

16     to improve the accessibility, quality, and

17     efficiency of primary care services, includ

18     ing health homes;

''(ii) develop and support primary care

20     learning communities to enhance the dis

21     semination of research findings for evi

22     dence-based practice, assess implementa

23     tion of practice improvement, share best

24     practices, and involve community clinicians

25     in the generation of new knowledge and

1       identification of important questions for

2       research; 

^[ii]

''(c) ASSIGNMENT OF MEDICARE FEE-FOR-SERVICE  BENEFICIARIES TO ACOS.-The Secretary shall determine an appropriate method to assign Medicare fee-for service beneficiaries to an ACO based on their utilization of primary care services provided under this title by an  ACO professional described in subsection (h)(1)(A).

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David McKalip, M.D., Neurological Surgeon

Individual Freedom - Hard to earn. Easy to lose.