Biology Reference
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model of care then starts looking more like models in socialist countries. While ACA
increases access to health insurance and thus non urgent care (hospitals bought into ACA
because it meant more of their patients would be covered including ER patients), the control of
costs does not take effect immediately. The cost saving is envisioned to be based on hospitals
taking responsibility of disease processes for a defined time period, as sort of HMO system
for hospitals instead of doctors. HMOs controlled costs for a few years by essentially placing
doctors at risk for any patient's care that was required. As predicted by Joseph Newhouse of
Med Pac at our Harvard Course, this would only be a short temporizing measure in controlling
costs. It was a generally very poor system because it potentially restricted care to needing
patients and it is likely the same could apply to Accountable Care Organizations, namely
avoiding adverse selection and moral hazard of over use as discussed before concerning
insurance companies. I had a young 40 year old patient who was dismissed by his primary care
doctor four times being told reflux was causing his chest pain when in fact he was suffering
from angina. Fortunately, he did not have a heart attack or die because of the lack of
investigation. With the ACA structure called Accountable Care Organizations (ACO), the
government will pay a certain amount for a diagnosis (Diagnosis Related Group, DRG) that a
hospital manages for a certain time period, pneumonia for example. The hospital gets a certain
amount and then takes care of patients, irrespective of the costs, although there may be some
“carve outs” for certain associated complications. One of the challenge is that patient
responsibility either for behavior or taking medications or costs are not part of the new law
and thus weakens both the likelihood of improved general healthcare (by prevention) or
lowered costs. This ACO DRG model has been used in Europe, for example in Sweden. While
the government pays a certain amount, the obvious danger is it can choose, on the basis of
budget constraints, to pay less to hospitals in subsequent years, and that will clearly happen as
already happens on a regular basis for current RVUs or DRGs. The hospitals then have to cope
with these lower reimbursements to take care of patients. The implications are obvious. In
Sweden, a friend of mine ran a large heart surgery program. He was given a certain amount
and it was then up to him as a physician to ration healthcare. He could to choose to do one
heart transplant versus doing ten aortic valve replacements, the latter which cost him
considerably less. Similarly, my late 60s aunt was refused a mitral valve replacement because
she was “too old” and my uncle who was of a similar age who had just retired was injured by
a tractor on our farm was refused dialysis and died. The government can wash its hands and
say it is not rationing healthcare, the doctors are, but if this course is followed we can expect
that in the next decade expensive procedures, like heart device procedures, will become more
restricted. This would lead to a reversal of our epoch of most incredibly successful and high
quality healthcare within our civilization. Just because the USA does not score well on infant
mortality does not mean the health care is not the best in the world. [Clearly there are no easy
answers and the CBO predicts CMS spending over the next decade will double to $1.8
trillion, which is 7.3% of economic output. However, this does not take into account the
doctors not getting paid if reimbursement is cut by a third or more. A graph I use from the CBO
produced in 2007 calculated that over the next 75 years, CMS was underfunded by an
incredible $35 trillion as mentioned. However, with the new spending the amount is even more
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