ACO  The health care plan:
Of course the point of this web log is that if we do not recover from our prejudice against marrying cousins and do it (not first cousins) the world’s fertility will continue to fall until we are all gone.  So this is off topic, but it is timely and it is tangentially involved.

Last Thursday night I went to a meeting of the Pinellas county medical society.  The meeting was private, but I see no harm in telling you what I learned.  I will include ideas from the lecture, ideas from the audience and my own notions without necessarily mentioning the source.  I am no expert and took no notes so do not take this as more than hearsay.  If you are interested in a professional opinion I shall try to find a proper referral for you.

The topic was the new health care plan for the US.  All the hype had been about so many people not having health insurance.  So far as I knew the law was going to require people to have insurance and the government would pick up the tab for anybody who really could not afford it.  But there is more. 

The law requires anyone whose health care is being subsidized by the government to get that care from an organization called an Accountable Care Organization or ACO.  This organization must provide care for a “definable part of the population.”  That means 5,000 people.  There must be enough doctors to provide their care, which means at least three primary care doctors, and a number of specialists.  It needs to be a big multi-specialty organization.  Since the insurance companies always follow the lead of Medicare, or government subsidized care for those over 65 (That’s everybody over 65.  If you don’t sign up promptly you are fined.  I was.)  It means that these ACO’s will provide all the health care for the country. 

Right now 79% of health care is provided by doctors who are practicing alone or with one or two others.  There are a number of massive multi specialty groups.  I used to work for one.  And there are specialties like radiology, both diagnostic and therapeutic, that require enormously expensive equipment, so many of them are already in such groups.  But evidently the vast bulk of the family practitioners and pediatricians prefer to be independent.  Their freedom costs them dearly.  Either they take an enormous amount of night call – at hazard to their own health – or they have a service direct every night phone call to an emergency room or 911. 

And now that has all been changed by law.

These ACO’s are also burdened with a number of new administrative tasks.  For instance there is – to me opaque – language that requires a system for encouraging evidence based medicine.  Now what in the world is medicine if not evidence based?  In 1910 the Flexner Report was published that, among other things, advocated training doctors as scientists.  The impact of that book has never completely faded.  Doctors are trained scientists and scientists are guided by evidence.  Of course as you well know, scientists are quite capable of ignoring evidence, and personal ambition and other incentives control them as well, but the name of the game is evidence.

There are to be mechanisms for following “outcomes.”  For instance Medicare already tracks lists of hospital stays.  If a doctor’s patients are staying in hospitals longer than average, pressure is applied.  So a lot of doctors “gamed” the system and discharged patients prematurely and then readmitted them.  This is counterproductive, expensive and dangerous.  So now the readmission rate is being watched.  Keeping track of such things requires skilled people, so administrative costs rise.  One way to control them is of course economies of scale.  So ACO groups will be under pressure to become ever bigger.

And the law has teeth.  One of two possibilities seems to be on the horizon.  Either the government will give the ACO a flat fee for each patient with a given diagnosis or – this is truly Mephistophelian – they will hold back 25% of the fee-for-service payment now made until it is found that the ACO is in 100% compliance with each and every regulation.  Not a passing grade of 80%, not an A of 95% but absolute perfection.  Fat chance. 

And the typical office, that crucial 80% of American medicine, simply cannot afford that.  They will have to close.

Regulations are different from laws.  Laws are enacted by the legislature so you can see them coming.  The regulations – what you actually have to do – are put together by office staff.  The law required that the regulations come out and the law go into effect the tenth of this month.  So compliance was impossible before that.  To this the response is, “Oh, the law is in effect already, but we just won’t enforce it until the regulations are published.  That was announced at 7 PM on the ninth. 

In all appearances it just won’t work.  Doctors are being asked to do something they cannot. 

Perhaps you remember Sadam Hussein, the Iraqi leader who was told we would go to war with him if he did not prove he had no weapons of mass destruction, which of course he did not have and at the cost of his life could not prove he did not have.  You could not prove you don’t have a weapon of mass destruction yourself.  If you tried to make one now you would make a cyber trail that stank to high heaven so before you were done you would be arrested, and the rest of your life would be most unpleasant.  But if you had started many years ago, you could have developed the skills, accumulated the equipment, made it, buried the thing in the woods and covered your tracks.  How could you or anyone else ever prove they had not done as much? 

So what will the doctors do?  Many will simply have to close their practices.  Some are old enough to be able to afford that.  Some are young enough to start another career.  Pity those in the middle.  There is no glut of primary care doctors, but rather the reverse.  And their incomes have already been driven insanely low.  The future of health care does not look bright.

Ah, but the Republicans are trying to get the bill reversed, right?  Well parts of it maybe, but nobody is going after the ACO part.  That stands unchallenged. 

But why would anybody want to do such a stupid, even wicked thing?  The rationale handed about is that doctors do not practice preventive care because they make more money if more people get sick.  I have never been aware of that.  There was a study done many years ago at the Massachusetts General Hospital that maintained that it was not cost effective to do skull films on people with head trauma.  If there was no clinical evidence for neurological damage, then any tiny fracture would be of no consequence.  Well they tried.  Of course a skull film is not exactly one of your fabulously expensive studies.  And of course if it comes to litigation it is quite interesting to know whether the skull was cracked.  But the saving would not have been great at all events, and the notion that the “wasted” money was motivated by doctors trying to let people get sick in order to earn more money just won’t wash.

Doctors do practice preventive medicine.  I have watched it from both ends of the socioeconomic scale.  They prescribe the same treatments for high fat content in the blood, for hypertension, for diabetes and the same counseling about diet and exercise to the most indigent and the mighty of the earth.  Does it work?  Globally speaking American health is quite poor for a country of our wealth.  There cannot be much more money to save by motivating doctors to do exactly what they went into medicine to do. 

In fact, of your health care dollar, not that much goes to paying doctors.  Years ago I heard that the majority of the dollar goes to administrative costs of insurance companies.  Administrative costs do not look like they are slated to fall.

So the idea of saving money by flushing out unscrupulous doctors does not justify endangering or destroying the present health care system, flawed though it is. 

So why is the government treating doctors like this?  Of course medicine has become big money, and people in power would like to control it.  Banking and car manufacturing are also big money, but the moment the government has to bail one out and winds up owning it, the pressure is on to get rid of it.  Having the government own the means of production or services is called communism.  Nobody else is treated in the high handed fashion that doctors are.  As a weary medical student it occurred to me that I was being pushed out of my comfort zone.  I once worked a hundred hours straight at Boston City Hospital.  No airline pilot would be permitted to do that.  It would be against the law.  The government does not tell anyone else how much to charge for their goods and services. 

I do not know, but it occurs to me that doctors are bright, educated people who are mostly small businessmen.  They have economic independence.  United, they would be an unstoppable political power, there are that many of them and their financial and intellectual resources are far greater than average.  That’s not because the pay is so good but because, at least until recently, they worked such brutal hours.  If you are in power, that kind of latent energy is scary.  We may be looking at the demise, or at least the possible end, of real independence in the country.  From now on we will all be parts of “definable parts of the population” and thus subject to control.  Notice the form in which your opinion is asked.  It’s multiple-choice in the polls.  Those are the opinions you are permitted to express.   I read a poll in which there were 142 possibilities for the end of the United States.  I am sure they did not include, “We never wise up and marry cousins so we run out of babies and the population tanks.  The social safety net cannot support the remaining population and we go out with mass elderly suicide.”  But the doctors are really harmless to the powers that be.  Doctors just want to take care of their patients.

I shall now very much stretch a point and relate this issue of ACO’s to fertility.  Ignore it if you like:    If a group of people wants to have babies, enough babies to survive, that group must act as a kindred and keep their gene pool size pretty much exclusive and somewhere in the hundreds.  Evidence for this is elsewhere on this web log.  According to Robin Fox of Kinship and Marriage, there has always been war between the kindreds and the authorities, which is to say the church and the state.  Look back at the number 5,000.  It is simply too big to be a kindred.  Maybe it is the kindreds and not the doctors who are the real targets. 

I have always thought that this infertility question should be addressed by the federal government.  It is after all a matter of the vital interest of the country.  The meeting was not encouraging along those lines. 

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