No, I have not changed my opinion about poor quality of this law– but this title works better in search engines. For new readers, a brief explanation of my purpose in the PPACA posts: I am reading, slowly, the actual law and giving my perspective. My intention is not to explain it to you, since I’m not an experienced legal analyst, but to inspire you to read at least some of it yourself and get into the conversation. This is a huge bill that will have enormous impacts on our health and our economy. In comparison to the better option of a universal, comprehensive national health insurance program, it falls far short. It does not cover all of us, and the coverage it does plan to provide will be unnecessarily expensive. And most importantly, it entrenches the private insurance corporations, who count any premium money spent on our health care as a loss.
This week, I have covered sections 2704 through 2707, which deal with some optional “demonstration” (pilot) projects available to the states, for Medicaid patients.
First, Section 2704 is a project that will be tried in 8 states (not specified yet which states). It involves paying hospitals a single, capitated fee for all the care involved in a Medicaid patient’s hospitalization– this is also called “bundling”. Capitated, from the Latin word for head, means per patient. It would replace a fee for service arrangement where Medicaid would be billed for the different parts of the stay, such as various procedures and physicians who saw the patient. The hospital would decide how to distribute the single fee– how much it would pay the physicians, for example.
There are pro’s and cons to the practice of bundling. The intention is that it pushes hospitals and providers to work harder to keep from wasting money. Can they get a better deal on a certain supply, etc? Do they really need to be using super-drug X or is it no better than tried-and-true drug Y? Does the pediatrician really need to call in a specialist or can she go and research the patient’s condition herself just as safely?
We have lots of evidence that expensive care is not necessarily better care– often it is actually the other way around. And something like an unnecessary CT scan isn’t just expensive but also exposes patients to radiation for no good reason. A good primary care doctor (pediatrician, family medicine doctor or internist) who takes time to do an excellent history and exam, and who puts in time thinking about the diagnosis and plan, may often be able to come up with something that fits a well-known, long-time patient better than a specialist who hasn’t ever met the person. If I know, for instance, that a certain teenager reacts to the stress of exam weeks by developing multiple confusing symptoms, I certainly need to pay good attention to him when he comes in– you never know when the stressed out stomachache is actually appendicitis. But I am much more likely to feel comfortable telling him what to watch for at home, talk about stress management, and have him come back in a few days (or call him) to see how he is. In an ER, he might instead get a CT of his abdomen, lots of blood work which is almost guaranteed to have one strange result that will have to be chased but didn’t mean anything after all, etc.
On the other hand… there are pitfalls to capitation and bundling. What if the hospital decides not just to spend wisely but to cut corners unsafely? What if the pediatrician really needs to take the “phone a friend” option of getting a consult and doesn’t, both because it would cut her fee and because the hospital is pressuring her not to? These kind of things can happen both intentionally and unconsciously. I don’t really know what the ideal solution is, but I prefer the salary option for physicians in general. Under a salary, docs aren’t rewarded for wasting money or saving it, although they can be educated to be good stewards of money. However, some people say it might just make us lazy so that we didn’t want to see very many patients in a day. We are all human, so no system will be perfect.
Here’s another issue with bundling that happens in outpatient settings as well. Insurance companies have actually been doing this for a while– they look and see that a doc evaluated a person for a condition and then treated it, and they only pay for one part. For instance, the patient comes in for a funny mole, and the doctor evaluates it as possible skin cancer. The doc goes ahead and does a biopsy right then, so that the patient can be taken care of immediately. But the insurance may only pay for the biopsy itself, not the exam and thinking part. The problem with that is the decision making part really is separate! I don’t do biopsies and it wasn’t part of my training — I send anyone who needs one to dermatology or plastics (pediatricians generally don’t love procedures, I’ve found). But I did evaluate the child and make the decision to refer, so I can bill for that. But if my procedure loving family medicine friend does both parts, he doesn’t get paid for the thinking part. So what happens? You guessed it– that’s why you go in to some doctor’s offices and only get a diagnosis, then come back another day for a 10 minute procedure, missing 2 days of work. Because otherwise the doctor gets paid for only part of the work. We don’t do anything like that in our clinic, but I know it happens!
Section 2705 is a pilot project where certain “safety net” hospitals (ones who care for large numbers of poor patients) will get a global fee instead of a fee per patient. From that single fee, they will need to pay for anyone who is admitted. This might be the simplest thing, but of course there can be pitfalls– they might start throwing up more barriers to patients being admitted. I do not see anything in either one of these parts that says the hospitals have to prove every cent was actually spent on patient care and not the lobby– I hope the money doesn’t get to go into the hospital’s general fund.
Section 2706 is similar in intention, and addresses a trial of pediatric accountable care organizations. States will have an option to try this out– they would arrange to certify ACO’s and see if these groups can save money on patient care. ACO’s that save money will get part of it back as a reward. Same worries apply as above.
Section 2707 is about a pilot project for psychiatric care, but I’m going to save that for another post since this one has gotten long. Under a single payer, Medicare for All we will still have to face these issues around how payment is made– capitation, fee for service, global– and there is not an easy answer. However, at least we would all be in the same boat, which would perhaps give us more motivation to do a good job.
