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Found: More Health Care Rationing in the Affordable Care Act!

Rationing takes place when governments provide health care because everyone wants the best possible medical treatments, health care is expensive,  and resources are inevitably  limited.  Because the Affordable Care Act (ACA) greatly expands the role of government in providing health care, it’s no surprise that health care rationing will follow.  We’ve seen previously how the Independent Payment Advisory Board (IPAB) created by the ACA, will restrict available medical services by limiting what service providers will be paid.  Unfortunately,  IPAB isn’t the only rationing element in the ACA.  The Patient-Centered Outcomes Research Institute , (PCORI) is another entity to be concerned about.

PCORI is set up as a government sponsored organization that seeks to reduce medical costs by identifying medical practices it deems costly, ineffective, and unnecessary.  Comparative Effectiveness Research (CER), the process to be used to do this, involves research that evaluates competing medical treatments, procedures, devices, diagnostic tools, and drugs used to treat, manage and diagnosis medical conditions.  In effect, every option used to treat medical conditions will be evaluated for its effectiveness against every other possible option.   The results are to be made available to physicians, health care providers, patients, IT vendors, professional associations and, notably, Federal and private health insurance plans.

Doctors and other health care providers will, therefore, “be advised” of which treatments the Institute recommends.   First of all, using the CER method exclusively to determine medical treatment standards has been debated.  Secondly, is this really necessary?   The health care organizations already engaged in research are legion and include medical schools, teaching hospitals, disease-specific groups, medical specialty associations, and organizations like the Rand Corporation.  On top of that, government organizations such as the Federal Drug Administration and the Agency for Healthcare Research and Quality are also engaged in medical evaluations.

So, do we really need more research?   Not really.  Health care quality is not the heart of the issue here – it’s the cost of that quality.  Government experts, among them Donald Berwick,  the Administrator of the Centers of Medicare and Medicaid Services (CMS), see common practice and standard, shared solutions, the way to bring down the escalating cost of health care. (In fact, Berwick was named head of CMS when Congress was not in session because  his oft-quoted views supporting  health care rationing made his Congressional approval unlikely.)

The problem with imposing standard solutions on medical professionals is that health care isn’t a rote science.  If it was, physicians wouldn’t need 12 years of medical education.  They could just check the government database against the patient’s condition and follow the standard procedure.  We know that won’t work.  There are too many of us who don’t respond to common treatments and don’t have common symptoms.

During the rancorous Congressional health care reform debate, concerns were also raised over the similarities between the proposed PCORI and the British National Institute for Health and Clinical Excellence (NICE).  NICE controls costs by limiting what medical treatments are available to people using age, conditions, and cost, as well as effectiveness, as criteria.

To fend off these criticisms and ensure passage of the ACA, assurances that PCORI findings would not be used to mandate medical practice or insurance coverage involving age, conditions, or cost were added to Section 6301 of the bill.  However, this sub-section,  labeled “Limitations on Certain Uses of Comparative Clinical Effectiveness Research”, is a mass of contradictory legalese obfuscation.  Buried in what one critic labeled  “a rat’s nest of regulatory complexity”  is the admission that PCORI’s  findings, because they’re based on CER, can, indeed, be used to make Medicare  coverage determinations.

Given that insurance companies follow Medicare guidelines, PCORI standards are sure to affect all health insurance as well. Furthermore, mandating that insurance companies be made aware of the Institute’s findings is a veiled threat that covering non-compliant medical practices might be cause for lawsuits.  The same applies to physicians and other health care providers.

We’ve attained the medical gold standard with the highest cancer survival rate in the world.  This couldn’t have been done following PCORI standard practices and medical practitioners.  While we all recognize that health care costs need to be contained, we don’t want to lower the quality of our health care.  IPAB and PCORI are not the answer.

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