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Affordable Care Act: Glitches Beyond the Websites | Guest Blog

The addition of 30 million newly insured patients, many of whom will be subjected to unneeded testing, drugs, and referrals, may add significant costs to the already inflated healthcare budget, especially if they are unaware of the implications of a deductible.

Now that the government shutdown is over, it’s time to focus on the Affordable Care Act.

Many have written about website sign-up difficulties including the apparent mother of all the bad ones, healthcare.gov.

Here are some issues that may not have received as much attention.

My daughter, who has a master’s degree in mathematics and has been buying insurance for her family for 7 years, has noted a few problems.

She is uncertain what plans she is eligible for because she and her husband are both independent contractors, and their combined income is highly variable year-to-year. It is not clear what the income threshold is going to be based on—this year, last year, or what.

It’s going to be a tricky gamble between the lower deductibles offered by the exchange and the lower premium offered by her current insurance.

With her current private policy, she can opt out of maternity coverage, which is not possible with the exchange plans.

If a knowledgeable consumer is undecided, how are first-time insurance buyers going to fare?

Of course, I have not read the ACA (has anyone?). I am not sure if there are any provisions for controlling expenditures.

Look at these recent headlines.

CT, MRI Overused for Headache, Study Finds” and the story says “Despite current guidelines that recommend against CT or MRI for uncomplicated headaches, primary physicians have been ordering nearly $1 billion worth of scans per year.”

Florida doctors prescribe way more drugs than Colorado doctors” and the difference is only partially due to the fact that Florida has more sick elderly people.

The Thousand-Dollar Pap Smear” tells a tale of inflated charges and unnecessary testing for women in a community health center.

Someone I know had a partial mastectomy followed by radiation for an early breast cancer. She had a mammogram 6 months later. She received a phone call from her surgeon asking her to come for an office visit to discuss the mammogram result. The individual who called would not tell her what the interpretation of the study was. She made an appointment. The next day she got a written report in the mail from the radiology office stating that the mammogram showed only normal postoperative changes and no sign of any cancer. She suspects that the surgeon wanted her to be seen in the office so that a visit could be charged for.

A man was suffering from migraine headaches. Workup, including a brain MRI, was negative. He was referred to a neurosurgeon by his primary care physician. What could a neurosurgeon possibly add to the diagnosis or treatment of this patient?

The addition of 30 million newly insured patients, many of whom will be subjected to the unneeded testing, drugs, and referrals noted above, may add huge amounts of costs to the already inflated healthcare budget, especially if the newly insured are not aware of the implications of a deductible. I have discussed deductibles and patient naivete in a previous post.

An article in the Boston Globe points out that it is just about impossible to find a primary care doctor who is accepting new patients in the Boston area. Massachusetts already has nearly universal healthcare coverage.

Assuming they can get past all the website glitches and then figure out what coverage to get, will the 30 million newly insured be able to find a doctor who will see them?

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1000 page views per day, and he has over 7200 followers on Twitter.

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  • Maranon says:

    “With her current private policy, she can opt out of maternity coverage, which is not possible with the exchange plans.”
    Your daughter and anyone who has a policy do not have to change anything, they can continue as they are.
    The groups like cigna and kayser that have been managing their patients and their budgets quite well for a number of years and keeping their population healthy. There are limitations and most people get excellent care and their providers are happier that the
    solo practicioners. Is it scary? sure, but is more scary have people loose their homes because of illness and no coverage for pre-existing conditions. The PA’s and the NP’s will have a greater role to play to keep the masses healthy to free the physicians to care for the critical patients that require their expertise and advanced degrees.

  • Vince says:

    Really since the following acts you cited on worthless test and procedures are occurring now not because of the ACA but because of some combination of greedy and unawareness of current guidelines blaming this on the payer is perhaps not the proper target. Some have estimated that most drugs and procedures work poorly if at all. Lets see PSA testing has been questioned as have routine mammograms to the cry’s and shrieks of the gored profession who see the most benefit and profit from their fair haired boy. The latest beam therapy for prostate cancer has never been shown more effective than previous therapy it does however generate considerately more revenue. Lets look at some recent studies Here’s a piece from the Wall Street Journal
    “Spine Surgery Found No Better Than Placebo” By
    Joseph Pereira and
    Keith J. Winstein Aug. 6 2009.

    Which looks at Vertebroplasty a procedure done about 100000 time a year according to the Journal piece at a cost of $2000 to $5000 each . Yet as the Journal noted…. “But in the first two studies to rigorously examine the effect of the procedure, known as vertebroplasty, researchers found no detectable benefit when compared with a placebo”

    Perhaps that’s where to contain cost by eliminating unproven test and procedure

    • SkepticalScalpel says:

      Vince, I agree with you. What you have said is exactly why I wrote that there are apparently no provisions in the ACA to control costs. That’s why it’s going to cost someone (the insured? the government? the taxpayers?) a lot of money.

  • Vince says:

    Well we may agree that physicians over treat in the case of the back procedure mentioned above the same article notes that ‘ “The procedure, which is covered by Medicare, ranges in cost from $2,000 to $5,000.” and the lead author of the study notes that ““There’s rigorous evidence that [vertebroplasty] doesn’t work any better than a control intervention, and we should stop paying for it.” that is true for who ever the payer is . The real answer to exploding cost is to take the cash cow away from physicians . Not the ACA . Really as the article notes there was push back from the industry and the “we are the Doctor complex even arose before the study from the Journal …”“Most doctors in this country thought the trial was unethical, because they were so convinced vertebroplasty works,” said Avery Evans, a radiologist at the University of Virginia who participated in the U.S. study. ” No the blame for exploding cost of health care lies primarily at the feet of the medical industry.
    As one physician noted it is often difficult to convince a physician who is profiting from a procedure that that procedure is worthless. How would you prevent over-treatment in any system?

    • SkepticalScalpel says:

      Vince, I’m not sure what your point is. I said I didn’t think the ACA had any cost containment measures in it. It is very simple, insurance companies should not pay for procedures that have been shown to have no value. I’m certain that no one, even the most ardent believer in vertebroplasty, would do it for nothing.

  • Vince says:

    My point is simple medical cost are skyrocketing because to many test and procedures are done by physicians because they are profitable ; not because they are good for the patient or should I say customer. The ACA does not regulate bad medical practices [perhaps it should] since the ACA merely connects insurance companies with patients it would be up to the private sector to regulate what procedures are done.and paid for . Perhaps the fact that you describe this case “ardent believer in vertebroplasty,” when my feeling is that that most ardently believe in the $2000 to $5000 such service nets. Coincidentally 0n my screen one of the news briefs is labeled “PSA screening: more harm than good.”

    • SkepticalScalpel says:

      Vince, I agree that money drives the ordering of many, but not all, tests. For example if a doctor orders an MRI on everyone who has a headache, he does not profit from that unless he owns an MRI machine himself.
      It’s interesting that you would mention the PSA screening issue. If you will note a comment by “I Will Be Anonymous Too,” he or she thinks that preventive care will end up decreasing costs. Unregulated ordering of of PSA screening tests leads to excessive costs of the test itself, biopsies, surgery, radiation and complications.

  • I Will Be Anonymous Too says:

    The author of this article, who chose not to put her/his real name, does not show much understanding of either the contents of the ACA or the complex nature of public health. Beyond the couple anecdotes that the author uses as evidence for major problems, the author assumes that the expansion of health care will only increase costs.

    What the author ignores is that the reward system under ACA has been altered to no longer be fee-for-service and that insurance companies will award clinics/hospitals with set amount of funds depending on the procedure to use as they see fit. If the hospital can efficiently treat patients and stay under-budget, they keep the difference; however, if they must go over budget, they eat the excess cost. Also, there is no reimbursement for nosocomial infection or re-admittance, further driving the revenue stream towards quality rather than quantity of service.

    The author also ignores a basic principle that an ounce of prevention is worth a pound of cure, and that the cost of increased preventative care will vastly decrease overall costs of reactive care in the long term.

    This is a poorly written article that lacks any evidence or any convincing arguments to support its theme. Overall grade: D




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