Like most of you, I've been reading everything I can to understand the varying views on the Supreme Court justices' decision to uphold the Patient Protection and Affordable Care Act.
Yes, I have no life.
But what I haven't seen much about—dare I say anything—is that in upholding most of the law, the court validates its many pages that improve and streamline provider quality and safety of care. Even if the individual mandate had been tossed aside, there are more than 40 sections of the law that critically affect how we measure and pay for, and improve, quality of care.
By that I mean the healthcare that improves outcomes without harming patients in the process.
Quibble with the metrics or don't; they're pretty darn important. For it wouldn't matter much if we expanded access and made healthcare cheaper if the care that was provided was deficient, needless, inappropriate, or even harmful.
It is, after all, called the Patient Protection and Affordable Care Act.
Instead, the discussion has centered almost exclusively around access issues and consumer payments. It seems to be all about the legal arguments regarding coverage, and states' rights to care for the poor the way each state sees fit.
Like how much the public must spend to buy commercial insurance, how each state will create an exchange, what the fed's role will be in assuring that states do, how much in taxpayer dollars will be spent on subsidies, and who will be required to buy health insurance.
Almost nowhere do I hear mentioned that within the act's 974 pages are provisions imposing greater pressure on hospitals to reduce high 30-day mortality rates and 30-day readmission rates, which signal poor discharge planning and healthcare provider follow-through.
I’m hearing zilch about the law's requirement that how providers who are paid should be tightly linked with whether care was delivered according to the latest scientific evidence.
There's scant mention on the blogs or other media of the fact that the ACA penalizes hospitals whose patients suffer higher rates of preventable conditions such as falls, infections, or other serious medical errors. Or that it sets forth a process for establishing measures by which one can compare hospital emergency rooms, cancer care, ambulatory surgical centers, home health agencies, skilled nursing homes and patient experience, many of which are tethered to hospital payment determinations.
I haven't seen anyone mention that the law calls for an expansion of performance transparency in these government websites: Hospital Compare, Physician Compare and Nursing Home Compare.
Here's a specific example: Several sections of the act shore up, with financial support, the ability of local municipalities and hospitals to provide accountable and appropriate trauma and emergency room care through coordinated region-wide systems that don't exist in many parts of the country. In far too many regions of the country still today, patients aren't taken to the most appropriate hospital when they get in trouble; they're taken to the nearest.
Implementing these kinds of systems in areas that don't have them would almost certainly provide a very big bang for the buck in lives saved. That is an extreme example of improved quality of care.
It seems that almost every day, some high-ranking member of the Obama administration's Health and Human Services Department holds a news briefing to boast of another way the ACA has helped patients by improving coverage and benefits, either by lowering premiums or share of cost, or providing free access to preventive services.
During the most recent news briefing Tuesday, for example, HHS Secretary Kathleen Sebelius spoke of how the ACA has enabled more than 16 million people with Medicare obtain "at least one preventive service at no cost."
Among people who wanted the entire law upheld, I’ve heard grumbling over the last few months that the administration has done too little, too late to explain to average Americans the ways in which the law would help them.
In that news conference, Sebelius left the room after her opening remarks and turned the show over to Jonathan Blum, Deputy Administrator and Director for the Center of Medicare. So I asked him to respond to the criticism that the administration has dropped the ball on explaining the benefits of the Act to the American people.
He gave what seemed to be a scripted response which mainly addressed the same coverage issues, about how under the ACA the "beneficiary community" has been "actively searching for health plans that have the highest value and lowest premiums," and are taking advantage of the donut hole program, and how the ACA "will reduce overall out-of-pocket expenses."
He then got a little closer to the point I am trying to make, but still fell far short.
"But I think more important," he said, "we are communicating that the Medicare program has changed fundamentally, to keep beneficiaries well and to keep them healthy...The Medicare program has shifted from a program that cares for beneficiaries when they're sick but also to one that keeps beneficiaries well and healthy and focuses on their patients needs to the greatest extent possible."
Aside from the U.S. House of Representatives 31st attempt on Wednesday to repeal the act, this legislation still has a long way to go. (The bill was approved by a vote of 244 to 185. It is not expected to be approved by the Senate.) As Atul Gawande, MD, said in a recent article in the New Yorker: "Many levers of obstruction remain; many hands will be reaching for them."
The administration can and should be much more out in front about the legislation's mandates to improve quality with as much forcefulness and gravitas—preferably even more so—to explain how this legislation doesn't just deal with money and coverage. In so many very specific ways, it holds the promise to actually improve health and prolong life.
Why is that something to hide?