The ACA to the rescue says the Washington Post! Really?

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A recent Washington Post editorial (12/19/14, “Obama deserves some credit for the good news about health care.”) praised aspects of the Affordable Care Act (ACA, aka Obamacare). The editorial pointed to some promising trends in health care. There has been a slowing of growth in Medicare’s costs, although those costs do continue to increase. Deaths from hospital errors have decreased dramatically by one report (100,000 deaths down to 50,000 deaths), while there are fewer falls, ulcers, and catheter related infections in the hospital. 30 day hospital readmissions have doped by 1.5%. And, perhaps most saliently, the number of uninsured Americans continues to drop.

Certainly there is much to praise about the ACA, especially the increased ability of Americans to obtain health insurance and the fact that pre-existing conditions will not prevent sicker people from being insured. Also, due to both ACA and Medicare reform, hospitals are making a concerted effort to cut their short-term readmission rates. But to credit the ACA for a drop in hospital errors is not only absurd, but it also assumes that the drop is a sustainable and legitimate statistic; only more time will show that. But most concerning about the Washington Post editorial is its failure to elucidate what the ACA has not accomplished, and the multiple assumptions and regulations built into the ACA that may actually be making health care worse. Because newspapers like the Washington Post do not talk to practicing primary care doctors (and because they have not read my book!), they are blind to a certain reality: the ACA is causing severe damage to the care of patients on the most basic level that, in the end, may have catastrophic ramifications. To learn about that, you have to look at primary care.

As I mentioned in my previous blog, the ACA has done nothing to reverse our accentuating shortage of primary care doctors. Without primary care physicians, there will not be enough doctors to see all the patients now being insured under the ACA’s auspices, and patients will be thrust into a specialized model of care that leads to more tests, procedures, medications, hospital stays, and worse outcomes, all at a much higher cost. Studies that I discuss in my book show, in fact, that specialized care leads to increased hospital rates, more hospital errors, and subsequently to more unnecessary deaths, which is why it is absurd to credit the ACA for reducing hospital errors and deaths. Remember, a reduction in 30 day hospital readmissions does not imply that there are fewer hospital admissions, as I discuss at length in my book. If anything, the push to hospitalize elderly people who live in the community and in assisted living facilities is actually accelerating in the ACA medical universe.

The Post’s blind praise ignores what the ACA has instigated at the primary care level. New rules are dissuading primary care doctors like me from treating elderly people palliatively at home rather than sending them to the hospital. ACA regulations are turning primary care doctors into automatons who must generate onerous time-consuming notes on their computers and prove compliance with often detrimental quality standards instead of actually taking care of their patients meaningfully and keeping them away from aggressive care. The ACA is all about quality indicators, unproven standards to which all of us must now prove compliance, which cost our practices money and squander our time, and which at best are not helpful and at worse actually harmful to the elderly patients we are treating. We also must generate burdensome notes in our computer whenever we see a patient, following a very strict template that Medicare has forced upon us; instead of listening to patients and discussing issues with them, we stare at screens and type away madly so we can complete our note before the patient leaves the exam room. Instead of talking to our patients about their health, their needs, and issues of quality, we measure and treat numbers, order tests, fill out forms, and look for and “fix” medical conditions in ways that verge sharply from true quality health care. This is what the ACA has done to us in primary care.

But that is only the tip of the iceberg. Under the ACA it has become virtually impossible for me to keep my elderly patients out of the hospital. Although I and my patients realize that hospitalization is very often the most dangerous path to take, especially for the frail elderly, the ACA, coupled with Medicare, has left me no other option. Calling 911 and sending elderly demented patients to the hospital is easy. For me it takes no time. For my patients and their families, it is a far less expensive approach than trying to be treated at home, something not paid for by our heath care system under Medicare and the ACA. Also, the ACA has made it much more difficult for me to help patients acquire medical equipment, home health nursing, oxygen, and other necessities; the forms and phone calls required for such basic care under new ACA rules take far too much time for a primary care practice to accomplish. And even if we do work to obtain such equipment, insurance will not pay for IV treatment, home health aides, and a rehab hospital stay; hospitalization is necessary for all of that under Medicare and ACA policies. We have actually moved backwards since the law took effect. I have seen assisted living facilities toss huge numbers of frail, elderly patients into hospitals despite the patients’ wishes not be hospitalized; the families and patients simply cannot financially afford to stay in their safer environment and be treated in their own rooms, and the facilities cannot afford to spend the time and resources necessary to avert an unnecessary and dangerous hospitalization. The ACA has not helped remedy this situation. It has only made it worse.

Before the Washington Post and others praise the ACA for anything other than increasing the number of insured Americans, they need to talk to us(primary care doctors and patients primarily) who understand what is really transpiring in health care. They will learn some very disturbing truths, many of which I elucidate in my book, others which are being more apparent every day. ACA reformers believe that by tossing regulations and disincentives at the current dysfunctional hospital and specialist based health care delivery system they will instigate profound changes. However, until they address the root of the problem, and start to focus on what factors—financial, cultural, logistical, educational—drive our system in the direction of low quality and high cost, all that ACA reformers are accomplishing is making the system even more complicated and flawed, as they decimate any semblance of primary care and instead rely on hospitals to orchestrate change. The Post is correct in stating that it is time to stop bashing the ACA and to start fixing its inherent flaws. But until the press and others start to recognize those flaws at the most basic level, then meaningful change will remain a very distant illusion.

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