Day 1 of 206- reading the Senate Health Care Bill

As a physician in full-time practice, reading the 2400+ page Senate health reform bill seems a daunting task.  Indeed, most physicians I know have not read the bill, and we rely on the press or “expert” analysts to give us a summary version.  Yet, in my experience, these summaries are inadequate at best for getting the full picture.  Therefore, I have set out on a quest to read, page by page, the Patient Protection and Affordable Care Act.  At 12 pages per day, I can finish in approximately 206 days, the number of bones in the human body.  I will share my thoughts on every dozen pages right here.  Check in regularly to follow me on my quest.

Pages 1-17 are the table of contents, so I am skipping those

Pages 18-29

Establishes rules for health insurance plans:

• Cannot put lifetime limits on the amount they pay
• Cannot put “unreasonable” annual limits on the amount they pay
  • here they point to section 223 of the internal revenue code for a definition of “unreasonable”- no idea what that could mean
• Cannot disenroll participants from their health care plan once enrolled, unless the participant commits some form of fraud

Requires insurance plans to cover preventive services:

• Must cover all “evidence-based” items that have an ‘A’ or ‘B’ rating from the US Preventive Services Task Force
  • This includes basic things like blood pressure and cholesterol screenings, etc.
  • Includes immunizations and “evidence-based preventive care” for children
  • A specific provision was made to ignore the most recent USPSTF recommendations on breast cancer screening, and to revert to those prior to Nov 2009
  • The HHS Secretary can establish a minimum length of time between when a recommendation is released and when insurance companies must start covering the recommended procedure/treatment- must be at least one year

Allows the HHS Secretary to develop guidelines for “value-based insurance plans“.

In these types of plans, the more effective a therapy, according to the latest evidence, the lower the cost to the patient.  On the other hand, patients will have to pay more for therapies that have no “proven” benefit.

Extends the age of dependence to 25.  Parents can claim unmarried children as dependents on their plan up to this age.

Outlines how the insurance plans must presents a summary of benefits to enrollees.

• Can’t be more than 4 pages, has to be 12-point font
• Must be presented in a “culturally and linguistically appropriate manner”
• Goes on to describe what must be included in the summary
• Imposes a fine of $1000 per enrollee if insurance company willfully fails to provide this information

My Thoughts

Prohibiting health insurance companies from setting lifetime limits or disqualifying patients seems like a good thing.  It wouldn’t seem fair for an insurance plan to drop someone just because they contracted a serious and expensive-to-treat illness.  On the other hand, what about the people who continue to smoke or engage in other unhealthy behaviors?  Should we all have to pay for their health care costs, too?  Under this arrangement, we would have to, because the only reason an insurance plan could drop a heavy smoker, for example, would be if they lied about smoking on their application.  The plans will have no choice but to pass along the costs to the rest of the plan members who strive to live a healthy lifestyle.

Relies heavily on “evidence-based” principles.  Also sounds good, but this can be dangerous, as Dr. Jerome Groopman points out in the article I highlighted in a previous post.  The Senate specifically singled out one piece of science they would not follow.  It’s funny how politicians like “evidence-based” recommendations until they are politically unpopular.  The USPSTF’s recent breast cancer screening recommendations were the essence of evidence-based: the panel came to their conclusion because the science did not support routine mammograms for women in their forties.  Cost was not a factor they considered in their analysis.  Yet, because of the public uproar caused by this announcement, the Senate went out of their way to reject this specific USPSTF recommendation in the bill.  This decision had nothing to do with science- only emotions and politics.  It points out that for all the talk about evidence and science, politics and emotions often win the day, which is one reason why I think putting tough decisions like these in the hands of a few politicians or commission members will put patients in danger.

I have the same concerns about “value-based” insurance plans.  Patients will be forced to pay more for things that “don’t work” according to scientific evidence, yet we have seen case after case of an established “best practice” that turns out to be dead wrong.  For example, we put every postmenopausal woman on hormone replacement therapy in the 1990s.  This was considered a “best practice” until we discovered that is was giving women heart attacks and strokes.  Under a value-based plan, women and doctors who chose a different approach would have been penalized financially by insurance companies for going against the “best practice” of giving hormones.  This would have caused more doctors and patients to opt for hormone replacement, even amidst reservations about the safety of the treatment.  The same thing will happen with many procedures that turn out to be wrong, but when doctors and patients do not have the financial freedom to explore a different approach, it will be less likely that we will even discover that the current practice is not really the “best practice.”

Whew- a lot for day 1 but I learned something.  Hope you did too.

(Let’s see, if I’m going to do this in 206 days I may as well assign a bone to each day.  Let’s start at the top and work our way down.  So Day #1 will be represented by the right parietal bone).