June 29th, 2012

What Does the Supreme Court’s Upholding of Healthcare Reform Mean for Doctors and Patients?

CardioExchange invited  clinicians and health policy experts to weigh in on what the upheld Affordable Care Act means–good or bad–for doctors and patients. Here are our initial responses. Share your thoughts with us and with your trusted colleagues.

Jack Lewin, MD (Principal, Lewin and Associates, Health Innovation Strategies; former CEO of the American College of Cardiology)

Given the surprising but very positive decision by the Supremes to uphold the Affordable Care Act, the challenge now is to work on improving outcomes at lower costs to help make our current unstable system sustainable.  The ACA is already having powerful positive effects. One member of my family has a significant medical disability, for example, and without the ACA’s coverage of high risk “uninsurables” this person found getting insurance almost impossible previously. Many seniors who were patients of mine tell me they can now afford their necessary medicines more easily due to the Medicare “doughnut hole” coverage in the ACA. Thanks to Chief Justice Roberts for seeing the value to building on what is already in place, if imperfect. It’s real progress.


Harry Peled, MD (Medical Director of In-Patient Cardiology/Non-invasive Lab & Medical Director of Critical Care, St. Jude Medical Center in Fullerton, CA)

1.) I am grateful that my college-bound daughter can be insured for a reasonable cost

2.) Chief Justice Roberts has earned tremendous credibility for himself and the court

3.) The Act does absolutely nothing to control medicare costs or reduce either inappropriate care or industry influence. (see for example, my post on the wearable ICD).  These issues pose serious dangers to our system.  We have twice the average healthcare costs of the rest of the developed world, and rather than addressing this issue, the current law mostly shifts these costs around.

Sorry, there are no polls available at the moment.

9 Responses to “What Does the Supreme Court’s Upholding of Healthcare Reform Mean for Doctors and Patients?”

  1. Cost containment is the biggest problem facing healthcare in the US. The “Affordable Care Act” is like most federal laws, best understood as the OPPOSITE of its official title. By inserting more federal regulation into healthcare, costs will only increase more rapidly! For all the wonderful promises made in this bill (which is why we are tempted to “celebrate”) there will be a huge increase in the taxpayer burden. What percentage of federal government programs end up costing less than DOUBLE the original projections?
    The only approach to health care delivery that can save us from ourselves (patients AND doctors) is a market-based one. Patients must have more (not less) “skin in the game”, forcing them to become cost-conscious, and in turn forcing physicians and hospitals to become more cost-conscious.
    Probably the only realistic way to move towards market-based health care is to (1) allow selling of health insurance across state lines (to foster competition) and (2) otherwise limit government regulation of healthcare to the state level. This will give us 50 chances to experiment and get it right.

    • Jonathan Levi, MD says:

      Dr. Brinton: These “Cost-consciousness” arguments constitute a cruel deception. There is no “cost-consciousness” issue for a patient of mine with intractable pain, bladder and bowel incontinence, and spinal canal and foraminal stenosis; or another patient with previous colonic polyps and recurrent GI bleeding; or another with severe bleeding from fibroids; or another with a left shoulder dislocation and a comminuted fracture; or an insulin-dependent diabetic who has lost toes from both feet because he couldn’t afford insulin over many years; or a man who is losing his left kidney due to a non-passing, obstructing ureteral stone. These patients, some of whom are working (the diabetic with amputations is supporting his disabled wife) but are all uninsured, simply can’t afford the treatment they need, and are suffering greatly thereby. May I respectfully suggest that you spend some time in an outpatient clinic like mine, and see what these real-world patients are experiencing?

    • Dr. Brinton: Doctors, not patients, make decisions about what tests to order. Therefore, we need to make sure that doctors, not patients, have “more skin in the game”. If a doctor orders unnecessary tests or procedures he, not the patient, should be financially penalized. Patients don’t go to medical school and are not liscensed to practice medicine. They do not have the expertise to know what is or is not indicated for their medical problems, only doctors do.

      I agree we need a market based system in which doctors who provide the best outcomes at the lowest cost are paid more. In order to do this the severity of illness adjusted outcomes and the costs to achieve these outcomes must be measured for each and every doctor. Then those doctors who achieve better outcomes at lower costs should be paid more. The the market system will have doctors competing against each other to lower cost and increase quality. That is how a market based capitalistic system works. It is not up to the patients to make medical decisions it is up to the doctors. Only the doctors can be held responsible in a medical marketplace. This is just basic economics 101.

  2. Matthew Carr, MD says:

    As a physican who see hundreds of pts that have no insurance and use the ER when their bp or chf meds run out , I truly belive that having health insurance will allow these people to find out pt treament at a fraction of the cost to society, both in the reduction of unecessary ER visits at outrageous costs , and the reduction on renal fiaure, strokes and chf that will accrue form better simple medical care. Those who dont undersand this, probably dont work in emergency rooms or are just unwilling to abandon their misunderstanding of “market force”

  3. Lillian Rhoades, AAS says:

    The devil is in the details. It’s amazing how many medical physicians are pontificating about the benefits or lack of benefits regarding this law when so much of the law is yet to be revealed. Have we not forgotten what former Speaker of the House, Nancy Pelosi, once said.
    “You have to pass the bill before you know what’s in it.” Okay, now the bill has become the official law that governs health practices in the country. Now, let’s see what’s REALLY in it. I suspect there will be enough pain for both the pros and cons to absorb.

    At best, government sponsored programs are Robin Hoods – They rob Peter to pay Paul until Peter has nothing left. And then come the deficits, expanded government, and higher taxes. Will this be any different? We’ll see.

  4. Stephen Hansen, md says:

    Look at the Swiss–all provider classes negotiate fee schedules every 2 years. They provide more with less by wringing the fat out of overly lucrative parts of the system.

  5. Dr Levi: it is true that patients with catastrophic illnesses cannot be asked to be “cost-conscious” in the sense of forgoing needed treatments. For this reason, insurance in the classic sense, coverage for catastrophic loss, is absolutely necessary for healthcare, and virtually all (excepting perhaps a few truly wealthy who wish to “self-insure”) need to have this coverage. Even in such cases, however, the patient must retain some incentives to have his/her care done in a cost-conscious manner. There is at least some flexibility in spending in all cases, and surely in choosing the details of care it is always important to strike the proper balance between overspending and underspending. The best way to implement these principles on a system-wide level remains to me an open question, but one we will never answer unless we agree on the issues we must address. Perhaps letting 50 states experiment, each in its own way, is a reasonable approach.

    Dr. Schneider: yes the doctor is as much or more involved in spending decisions than is the patient. The problem, in my view, with placing the physician at financial risk is this. If the doctor is, in essence, spending his or her own money to care for patients, does this not pit the physician’s financial interests in competition with the patient’s health? Yes, we should all be doing healthcare for altruistic reasons, but whenever there are difficult decisions regarding cost vs. quality, I prefer not to have even a perceived conflict of interest. I think it is best to leave these difficult choices to the patient (with advice from the physician) where both sides of the conflict land on the same person, and a third party will not be tempted to judge.

    • That is precisely why we must simultaneously measure both severity of illness adjusted outcomes in addition to overall cost. Doctors who sacrifice quality to lower costs will suffer financial penalties. Doctors who use their expertise to lower costs while simultaneously maintaining the same quality outcomes will benefit financially. Doctors who both lower costs and simultaneously improve outcomes will benefit the most financially.

      There is no conflict of interest if the doctor is rewarded for better patient outcomes. Then the doctor’s financial interests and the patient’s medical interest are absolutely alligned. This mandates that BOTH the doctor’s outcomes and costs be measured. If a doctor sacrifices the quality of care in order to lower costs he should be financially penalized.

      This is how a market works. In a market the customer must know both what he is getting, ie severity of illness adjusted outcomes, and how much is being spent to achieve that outcome. Doctors who achieve both better outcomes and lower cost should be paid more. Doctors who lower costs but only with the result of worse outcomes should pay a financial penalty. Doctors who achieve better outcomes but only at increased costs compared to other doctors should also pay a financial penalty.

      A market is based on quality and price. Not one or the other. That is basic economics 101. If we want to increase quality and lower costs then both have to be measured. Quality and costs are determined solely by doctors, not by patients.

    • Jonathan Levi, MD says:

      Dr. Brinton: To a limited extent I agree, although I emphasize that I see what you call “patients with catastrophic illnesses” almost every week. Most of my working, uninsured patients accept modest copayments for basic tests, i.e., about $15-30 for a comprehensive metabolic panel, lipid profile, CBC or TSH (sometimes spread out over several visits). However, your “insurance in the classic sense” with “coverage for catastrophic loss” for “virtually all” patients is simply a degree of universal coverage (which then has to be mandated, or the young, healthy ones won’t buy and will drive up the rates for the others). To me, the only way this can be done is with minimal Federal requirements, whatever else the states “experiment” with, otherwise some states will invariably cut corners. See the United States Census Bureau’s 2009 report showing 20-27% of people without health insurance in California, Nevada, New Mexico, Texas, Georgia and Florida, and 16-20% uninsured in 10 more states (http://en.wikipedia.org/wiki/Health_insurance_coverage_in_the_United_States). Respectfully, JL