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Accountable Care Act Unconstitutional? The Fate Of Americans’ Health

A Florida’s judge’s ruling that the Accountable Care Act (ACA) is unconstitutional doesn’t resolve the underlying constitutional issue (which will ultimately have to be decided by the U.S. Supreme Court) but it has introduced new uncertainty for the $2.3 trillion health care industry, and emboldened the law’s critics to push even harder for repeal (not that they weren’t trying already).

The Wall Street Journal’s (WSJ) health blog reports that “states and companies that are supposed to be implementing the law trying to figure out what to do next. The WSJ reports that the 26 states that are parties to the suit are considering whether to ask the Supreme Court to take up the case now, before it has fully wended its way through the legal system. The New York Times (NYT) quotes the governor of Florida as saying that until the fate of the law is clear, “we’re not going to spend a lot of time and money” to implement it. Other states, even if part of the suit, will move ahead,” the NYT says. The WSJ also reports that most health care companies plan to “stay the course” and continue to plan for the law’s implementation. Meanwhile, the Obama administration says that the judge’s ruling will have no effect on the implementation of the law or the requirement that states (including those who brought the suit) comply with its mandates and claims that most constitutional experts agree with the administration.

Now, I am not a lawyer, so I don’t have any expertise on the legal arguments over the ACA’s constitutionality. For those of you who want to hear more about the constitutional questions from people who might actually know what they are talking about, I recommend this Health Care Blog post from attorney Mark Hall, a critic of the Florida judge’s ruling. He notes that “at least half of the relevant part of the opinion is devoted to discussing what Hamilton, Madison, Jefferson and other Founding Fathers would have thought about the individual mandate” (Judge Vinson concluded that they would not have approved of it) but “the same Founders wrote a Constitution that allowed the federal government to take property from unwilling sellers and passive owners, when needed to construct highways, bridges and canals.” The Washington Post’s Ezra Klein — a supporter of the Affordable Care Act — has posted an excellent overview of what legal experts are saying about the ruling, pro and con, including a link to a posting that argues Judge Vinson ruled correctly. Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

“The Hot Spotters”: Is Better Care For The Neediest Patients The Answer To Lower Healthcare Costs?

Author-physician Dr. Atul Gawande has done it again with a well-written article in The New Yorker magazine entitled, “The Hot Spotters.” It deals with the fact that 5 percent of people with chronic illness make up over 50 percent of all healthcare costs.

If we can zero in on providing better preventive care for those people, we can finally get our arms around runaway healthcare costs. How great that you don’t even have to have a New Yorker subscription to read it. Here are a few cliff notes until you get to it:

— In Camden, New Jersey, one percent of patients account for one-third of the city’s medical costs. By just focusing attention on the social and medical outpatient needs of those people, they not only got healthier but costs were cut in half.

— Our current system is unable to reign in costs. We need to completely re-design and fund how we do primary care.

— Charging high co-payments to people with health problems just backfires. They avoid preventive care and end up hospitalized with expensive and life-threatening illnesses that are much worse and more costly. Read more »

*This blog post was originally published at EverythingHealth*

When Money Isn’t Everything To Doctors

I recently pointed to a BMJ study concluding that pay for performance doesn’t seem to motivate doctors. It has been picking up steam in major media with TIME, for instance, saying: “Money isn’t everything, even to doctors.”

So much is riding on the concept of pay for performance, that it’s hard to fathom what other options there are should it fail. And there’s mounting evidence that it will.

Dr. Aaron Carroll, a pediatrician at the University of Indiana, and regular contributor to KevinMD.com, ponders the options. First he comments on why the performance incentives in the NHS failed:

Perhaps the doctors were already improving without the program. If that’s the case, though, then you don’t need economic incentives. It’s possible the incentives were too low. But I don’t think many will propose more than a 25 percent bonus. It’s also possible that the benchmarks which define success were too low and therefore didn’t improve outcomes. There’s no scientific reason to think that the recommendations weren’t appropriate, however. More likely, it’s what I’ve said before. Changing physician behavior is hard.

So if money can’t motivate doctors, what’s next? Physicians aren’t going to like what Dr. Carroll has to say. Read more »

*This blog post was originally published at KevinMD.com*

State Of Healthcare In The Union

Short and sweet. That’s how President Obama addressed healthcare reform in his State of the Union address [Tuesday] night. In less than 700 words, he outlined how he’d improve but not retreat on what’s been enacted into law.

He’s willing to work on changes, he said, naming malpractice reform and reducing onerous paperwork burdens for small businesses. But, he cautioned, “What I’m not willing to do is go back to the days when insurance companies could deny someone coverage because of a pre-existing condition.”

President Obama had invited two real people to his address to highlight the law’s successes. One is a brain cancer survivor who can access health insurance through high-risk pools created by the law. The other is a small business owner who lowered health insurance costs by $10,000 for his nine employees, a probable jab at the “job-killing” title of an attempted yet futile repeal vote last week.

The President’s remarks come at a time when the public is of two minds on healthcare reform. While many state they don’t like the entire package, they also love individual aspects of it. The individual mandate remains widely unpopular, but allowing those with pre-existing conditions to access insurance is widely popular, as does Medicare and Social Security.

The Republican response by Rep. Paul Ryan, R-Wis., Chairman of the House Budget Committee, responded that, “The President mentioned the need for regulatory reform to ease the burden on American businesses. We agree — and we think his healthcare law would be a great place to start.” The House has voted for a repeal and Senate Republicans are preparing legislation and promising to ask for a vote. (Los Angeles Times, Politico, Kaiser Health News, Greenville [South Carolina] Online)

*This blog post was originally published at ACP Internist*

Clinical Guidelines: Who Writes Them Anyway?

While DrRich is a conservative American, and has made plain the difficulties he has with the Progressive program in general and with Progressive healthcare reform in particular, at times he is forced to admit that, on occasion, the Progressive way of looking at the world has certain merits. And as DrRich contemplates a question that has been bothering him lately, a question that no doubt plagues many American physicians who (unlike DrRich) are still toiling away in the trenches, he finds that this is one such occasion.

That question is: Just who are the people writing all those clinical guidelines — the  “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?

DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.

But today, we have physicians clamoring to become GOD (Government Operatives Deliberating) panelists. These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.” Read more »

*This blog post was originally published at The Covert Rationing Blog*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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