Remember Mary Poppins singing, “A spoonful of sugar helps the medicine go down in the most delightful way”?
If so, be concerned, because you or your parents are probably on Medicare – or will be soon – and last week the Department of Health and Human Services (HHS) proposed regulations for Accountable Care Organizations (ACOs).
The sugar-coated rhetoric in this announcement from HHS cannot disguise the bad medicine in this part of this part of the Affordable Care Act, which intends to bureaucratically cut as much as $960 million in Medicare spending over three years. This ObamaCare prescription threatens patients, the physicians who care for them, and the common good. The only clear winners are the consultants and lawyers busy trying to decipher this 429-page tome of acronyms and encrypted methodology that will compromise the doctor-patient relationship and is contrary to the principle of subsidiarity.
Medicare beneficiaries will be “assigned” to 5,000 patient-minimum organizations to coordinate their care. While HHS Secretary Kathleen Sebelius talks about improvement in care, the politically poisonous truth is that Medicare is going broke and ACOs are designed to save money. The words “rationing” or “treatment denial” or “withholding care” are not part of her press release, but reading the regulations reveals intentions to “share savings” with those who fulfill, or “penalize” others who fall short of, the administration’s objectives. The administration’s talking points include politically palatable words which emphasize quality improvement and care enhancement when the real objective is cost control by a utilitarian calculus.
Physicians and other health care providers will find themselves in conflict with the traditional ethos of duty to patient within ACOs. Ever-increasing numbers of doctors are leaving private practice and becoming employed by hospitals, due to a variety of challenges inherent in these uncertain times. The hospitals are the most likely recipient of bundled payments for caring for Medicare patients. Doctors will face agency conflicts between the time honored primary duty to patient, which may conflict with hospital administration, and ACO goals of fiscal savings. Medical care providers will receive incentives for controlling spending, and penalties if they do not. "No one can serve two masters” (Matthew 6:24), not even physicians.
The physician’s ACO conundrum is illustrated in the language where these regulations proclaim: “Providers should be accountable for the cost of care, and be rewarded for reducing unnecessary expenditures and be responsible for excess expenditures.” Yet the very next sentence stipulates, “In reducing excess expenditures, providers should continually improve the quality of care they deliver and must honor their commitment to do no harm to beneficiaries” (page 14).
The principle of subsidiarity guides policymakers to empower decision making and scarce health care resource allocation at the doctor-patient level. However, the Affordable Care Act moves in the opposite direction. It increases bureaucratic power and responsibility. This is not the antidote needed to reform health care in the United States. The complexity, cost, and confusion of implementing these ACO regulations defy comprehension. We can only hope ACOs will follow “just say no” HMOs into the historical ash heap of misguided health policy.
There is no question that significant – and scarce -- health care resources are consumed in the Medicare population toward the end of life. ACOs intend to limit this spending -- the government way. The Ethical and Religious Directives by the United States Conference of Catholic Bishops suggest a better path forward:
While every person is obliged to use ordinary means to preserve his or her health, no person should be obliged to submit to a health care procedure that the person has judged, with a free and informed conscience, not to provide a reasonable hope of benefit without imposing excessive risks and burdens on the patient or excessive expense to family or community. (32)
The patient must be the focal point of concern. They, or their surrogate, with the help of their physician, need to become informed. They must also participate in the expense of their care, which will better allocate resources for the community than would more distant bureaucratic panels or regulation.
A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community (57).
Enabling all patients, with and without means, to “proportionally” participate in the cost of their care will better allocate scarce health care resources than further sugar-coated, and non-delightful, misguided administrative policies.
By the way, if you didn’t recognize the Mary Poppins song, that’s OK. Worry instead about your grandparents for now, and consider how your generation will counter-reform ObamaCare in the future.