Ten Things Health Care Consumers
May Not Know About the Accountable Care Act
The Accountable Care Act is perhaps the most meaningful of the 2010
health care reform mandates and a number of health care organizations have completed
their first year in the program. This article highlights some of the consumer
protection and cost cutting mandates and reveals the impetus for each element.
1-Application of evidence-based
medical care, as a means to evaluate and pay for health services
One of the results of the fifty-state, private payer national health
care panorama is there are a lot of differences in patient care patterns, with
some doctors ignoring the evidence based recommendations of national
organizations, which result in disparate clinical outcomes. This means significant
variances in patient deaths, re-admission rates for hospitalizations following
treatment, and medical complications. An example of this phenomenon is in
cardiac care, which has expanded the application of the very expensive cardiac
pacemaker devices from the initial 1984 list of fifty-six diagnosis to the 2008
guidelines now at eighty- eight.[1]
The problem with this robust expansion is scope-creep because only 5% of these
recommendations are backed by the findings of “gold standard” randomized
double-blind studies, which control for bias and are subject to rigorous
scientific controls. To put it bluntly, many patients have received pacemakers
for which the clinical research shows were not justified.
Cardiac device manufacturers like St. Jude Medical and Medtronic earn a
tidy sum, roughly $7,500 for each pacemaker device, regardless of what the
hospital receives in compensation and Medicare pays for most of these devices.[2]
The medical device companies have earned between 48% and 20% net profits for
years, meanwhile many hospitals serving
Medicare and Medicaid patients are starved for cash, as the current Medicare
reimbursement model rewards the device makers and the cardiac specialist more
than the hospital or the primary care doctor.
The creation of the Patient
Centered Outcomes Research Institute is an attempt to have an independent third
party entity audit and recommend treatment practices based on scientific
studies, especially for government funded health care programs. Many health
care companies are outraged about this new agency oversight, but it is directly
due to the opportunistic behavior of medical suppliers, specialists, and some hospitals
at the expense of the health care system.
2-Creation of the Medical Home
Criteria due to the over emphasis on specialty care while ignoring primary care
Facts of life in American health care include a plethora of specialists
swarming over a patient in an acute care setting, but no one coordinating
patient health over the care continuum. Medical schools produce more
specialists than primary care providers now and the specialists earn a lot more
money, which means political power in hospitals, medical associations, and in
the beltway. By way of comparison, the mean income of cardiologists in 1987 was
$271,555 versus less than $100,000 for primary care doctors, including family
practitioners and pediatricians. Medicare is primarily to blame for this
discrepancy as its reimbursement for clinical care has favored procedures and
not time spent with patients. Ergo the doctor who spends the most time with the
patient and may be the better practitioner will make less money.
3- Improved integration of
patient care by observing key diagnosis and patient outcomes and paying people
more for improved clinical performance
The Accountable Care Act links reimbursement payments from Medicare and
Medicaid to clinical outcomes, in an attempt by the government to provide
better stewardship of what we are getting for our health care investment. Specific
conditions that the Accountable Care Act Shared Savings Program includes are:
Chronic obstructive pulmonary disease (adult asthma), high blood pressure, heart
failure, stroke, and diabetes. The ACO mandates attempt to assess clinical
performance through a risk standardized assessment of chronic medical
conditions, by reviewing hospital data, with the goal being the reduction in
hospital admissions. In order to be eligible for the enhanced savings program
the Centers for Medicare and Medicaid require hospitals which participate to
report on the following metrics: patient caregiver experience, care
coordination and patient safety, preventive health, and patient management for
the at-risk population.
4-Accountable Care Act creates
bundled payments for renal or kidney dialysis which is a cost containment
measurement for this $78,000 per patient per year treatment, which is almost
entirely paid for by Medicare.
5-The Sunshine Act mandates
disclosure of financial payments from medical device manufacturers and the
pharmaceutical industry to health care providers.
The Sunshine Act, which is part of the Accountable Care Act mandates
disclosure of financial payments from medical device manufactures (aka cardiac
devices and orthopedic joints) and from the pharmaceutical industry to health
care providers, including doctors and hospitals.[3]
The highly profitable medical device industry has a practice of offering
on-site bonuses for using their lucrative devices, which are now being
prescribed for treatments which are not in compliance with evidence based treatment
protocols. So to assist the consumer,
the government is attempting, through this mandate to shine a bit of light on
conflicts of interest for treatment practices, so that you can make an informed
decision on your procedure and where you have it done.
6-CMS, the government agency
overseeing Medicare and Medicaid has established national performance metrics
for key medical conditions which impact 80% of the national population.
These benchmarks will establish a performance and reporting standard for all
organizations, regardless of whether they choose to participate in the ACO
Shared Savings Program. This new level of transparency will increase patient
safety as better information becomes available to health care consumers.
7-ACO attempts to improve care
for diabetes and heart disease patients
By requiring 100% compliance
with the six measures of clinical care, in order to achieve the increase in
reimbursement under the Accountable Care Shared Savings Program, CMS hopes to
stem the tide of these costly medical conditions. The measures of clinical care
include; health status, health promotion and education, caregiver to patient
communication, timely care, patient safety, and care coordination. This level
of scrutiny is based on the drastic increase in disease prevalence and the need
for the country to create a national intervention.
8-Establishment of the
Independent Payment Advisory Board to reign-in health care overcharging
The Accountable Care Act has created the Independent Payment Advisory
Board, which has broad authority to review and make recommendations for payment
changes for health care services under Medicare. This is actually an aspect of
the law that has great potential for cost containment authority, if congress
will not capitulate to the powerful medical industrial lobby by refusing to
deploy recommended changes. For example, why should cardiac device
manufacturers continue to receive such exorbitant reimbursements at the expense
of primary care services, so a realignment of payment could occur there. The
point of the IPAB is to slow the growth of Medicare, which is presently
escalating in an unsustainable fashion and everyone in Congress is in agreement
on this factoid.
9-Savings Generated from the
Accountable Care Act Will Shore-up the Medicare Trust Fund
The focus of the ACO mandates is to deliver better clinical outcomes
and to reduce the long term trajectory of Medicare costs. Since Medicare is funded
by payroll taxes and general funds, it is of concern to us all.
10-Accountable Care Act
Increases Funding for More Fraud Auditors
Medicare fraud has been a problem since inception, because of entrepreneurial
health care suppliers, clinicians, and hospitals. FYI the current Governor of Florida
was at the helm of HMA, a large hospital chain when it was convicted of
fraudulent Medicare billing, and he was asked to step down.[4]
The Office of the Inspector General has found that for every dollar invested in
fraud detection seventeen are recovered, yet a budget request for this in 2005,
was denied by Congress(medical industrial lobbyists at work again).[5]
So the next time you are forced to listen to the grousing about the
health care reforms and Obama care, just remember there are many consumer
protection elements which have the
potential to transform the health care paradigm in this country and that is
precisely what we need.
Feel free to share this article, written by Roberta E. Winter, MHA,
MPA, and the author of Unraveling U.S. Health Care-A Personal Guide. http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972
[1]
Knocking on Heaven’s Door, Katy Butler, Scribner, a division of Simon &
Schuster, 2013, chapter 12, p. 177, 2008 American College of Cardiology, Heart
Rhythm Society, and the American Heart Association update for treatment
guidelines.
[2]
Knocking on Heaven’s Door, Katy Butler, Scribner, a division of Simon &
Schuster, 2013, chapter 4, p. 64
[5]
It’s Enough To Make You Sick-The Failure of American Health Care and a
Prescription for the Cure, Jeffrey
Lobosky, MD, Rowman & Littlefield, 2012, chapter 13, page 208
