Our health problems will remain, despite how the Supreme Court rules

I was recently honored to attend a discussion at the White House, convened by Health and Human Services Secretary Kathleen Sebelius. It was one of those rare “clear my schedule immediately” invitations; I thank my patients and family for allowing me to take this last minute trip.

Physician leaders from around the country were invited to the White House for a dialogue with lead government health officials (specifically administrators from the Center for Medicare and Medicaid Innovation) over the challenges and opportunities health care providers face in the race to meet deadlines set by the Affordable Care Act (ACA). What followed was a fascinating, solutions-oriented discussion about how government can support and incentivize the provision of health care that both patients need and doctors strive to provide. As expected, common points of discussion were challenges to building a Patient Centered Medical Home (PCMH), achieving electronic medical (EMR) record meaningful use, and developing Accountable Care Organizations (ACO).

Now before you stop reading, give me a chance to make this migraine-inducing jargon make sense. Your experience with the health care system may change in the near future.

Let’s say your mother has a common collection of health problems. She has high cholesterol, diabetes, nagging low back pain, and has been depressed after a hip replacement surgery earlier this year. She takes medications of all shapes sizes, each with its own peculiar dosing schedule that is near impossible to keep straight. It seems she is constantly going to doctor visits of various kinds. She knows she needs to eat better but after each modest dietary adjustment she repeatedly settles back into her unhealthy diet. She (and you) feel discouraged. Contrary to your expectations, your mother’s clinic is making things worse. Her doctor, though well-meaning, does not have all of the records from past specialist visits. Most of the fifteen minutes at the clinic visit is spent figuring out if all the medications are being taken correctly, completing medication refills, and skimming lab results. Her doctor makes a passing statement about eating healthy with a knowing smile. Finally, the clinic visit sprint is over leaving both patient and doctor breathless. Your mother never got a chance to ask her specific questions, let alone connect with her doctor in a meaningful way. Both patient and the doctor are unsatisfied with the visit. Perhaps worst of all, your mother’s health is no better as a result. Sadly, this story currently reflects the reality in doctor’s offices across the country.

Cue in health reform. Included in the ACA and related regulations are incentivized models to address many of the challenges illustrated in the story above. The Patient Centered Medical Home (PCMH) offers a model for providing comprehensive, continuous, high quality care. This is how it could look for your mother. Your mother can easily make an appointment with her own doctor as soon as she needs a visit. At the visit her doctor steps into the room already up to speed on your mother’s problems because she has had ready access to past visits and specialty records through a recently installed electronic medical record system (see below). After the doctor visit, a pharmacist swoops in to help organize and schedule medications. Then a dietitian gives her practical, incremental diet change ideas that will be reviewed at future visits. A care manager stops by to pull everything together, reminds your mother about upcoming specialty visits, and schedules a home visit to see how your mother is keeping up with her care plan. From home, your mother can take ownership of her own health by accessing her lab results through an online patient portal. Finally, mom will be asked to regularly evaluate her doctor and clinic so their performance is responsive to your mother’s needs.

An advanced electronic health record (EHR) is vital to the ideal care you mother deserves. A set of standards called “meaningful use” was fashioned to ensure that these systems are designed for high quality patient care. Not only does an EHR designed for meaningful use keep medical files organized, it allows for sharing of records with other professionals, and creates mechanisms to follow health trends in a individual or panel of patients. My own clinic in Oakland is currently going through these growing pains.

While your mother’s care is improving, you may not even notice that her clinic is seeking to be a part of an Accountable Care Organization (ACO). ACOs connect primary care doctors with specialists and hospitals in a model that incentivizes good health outcomes or results. Currently, much of the health care system is set up so that providers get paid more for doing more — like more visits or more tests. Intentional or not, if someone gets paid based on the number of times they do something, the financial incentive is to do more, even beyond what is necessary. Ideally, any service provider, including doctors, should get paid for achieving good results rather than feeling the financial pressure to do more. ACOs allow providers together to decide the care and outcome standards that will be tied to income. These goals are intended to improve the quality of care while decreasing cost by avoiding unnecessary tests and procedures.


I think it can be summed up in this way: these changes strive to ensure “the right care, for the right person, at the right time.” Ironically, if we do this well, the total cost of health care should decrease.

So how is it going?

My first reaction would be to not-so-artfully dodge that question with an honest “it’s complicated.” The White House meeting involved a discussion about pilots of various models across the country (some with outstanding results). The government is hurriedly and rigorously trying to figure out what does and does not work so it can swiftly scale up proven models. The administrators we met with were eager to solicit ideas from providers and patients on the ground. Some challenges doctors highlighted included: how to tie in specialists into the medical home and ACO; the lack of reforms in child health; and how to incentivize good stewardship of health care dollars for higher quality care. I was pleased to witness genuine engagement from high-level government officials at this meeting. It gave me hope that through all this chaos, we will achieve a health care system that will be a big step up from where are now. All in all, good things are happening.

One last thing. There happens to be a very important Supreme Court decision coming out this month about the constitutionality of the Affordable Care Act. You can read or listen to my opinions on it. But let me leave you with this idea, as stated by one of the meeting’s key speakers. Regardless of what the Supreme Court decides, the problems that got us here are not going away. Frankly, as a patient and a provider in the health care system, our lives depend on rising above the status quo STAT.

Ricky Y. Choi is a pediatrician who blogs at SFGate and the Huffington Post San Francisco.  It reprinted with the author’s permission.

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  • David Hanson

    It seems that Obama served kool-aid at the White House when Dr. Choi visited.  And his post indicates he drank a lot of it!

    • http://profile.yahoo.com/HMN4N4FPON2WHNT7E7IEXO42N4 Steve Allen

      @DavidHanson- If you think that the government is more deceitful and lying than the insurance companies who’ve been dictating these things for years, then you’ve been drinking something worse than kool-aid!

  • http://twitter.com/rychoimd Ricky Y. Choi, MD

    Thanks for your comment.  The ACA is not perfect, but will make important strides towards improving quality and access for many Americans.  Alas, they the White House not serve refreshments.

  • David Hanson

    I don’t believe that it will improve quality or access.  ObamaCare was built on deceit and lies all the way and I don’t buy any of them.  The bribing of Senators by Obama, using false accounting by counting 10 years of taxes but less than 10 years of expenses,  are “if you like your health care, you can keep it” are the foundation that this Obama legislation was built upon. 

    Also, I wonder about access for Medicare age people (like I will be in 4 years).  Unless Obama lied about cutting the costs of Medicare, then seniors that already have problems finding a doctor who will (or more correctly financially can) accept Medicare patients will be MUCH more difficult.  Seniors access appears to be much less.  Then Obama’s regulations that require this and that (can’t all but the poorest women afford their own birth control?) are partisan and meant to stir up his radical constituency but raise the cost of health insurance for the rest of us. GRRRRR!

  • AuthenticBioethics

    I know I’m about to over-simplify, but I really do understand the layers of complexity involved. Yet it seems to me that third-party meddling in basic health services is a large part of what has gotten us into this mess in the last 40 years or so, and it therefore seems to me that the last thing we need to fix the mess is even more third-party meddling by the people least capable of it, the United States Government. 

    The Supreme Court’s role in all this is not to fix our health system, but to determine whether or not the president and congress have overstepped the Constitution in passing the so-called “Affordable” Care Act. It would be way better not to fix the health system than to do so by unconstitutional means. 

  • kjindal

    Where are all these resources coming from for the frail elderly Medicare population? You envision tripling or quadrupling the manpower per patient encounter without an impact on cost? And where are the other primary care docs coming from?

    And for electronic records to talk to each other, this administration needs to just pick a ‘winner’ and give it for free (and mandate its use) to any entity billing Medicare. For that to happen they have to stop closed-door meetings with EHR vendors.

    You are trying to tie together conflicting agendas of flushing out a healthcare ‘team’, control costs, and address ‘customer’ satisfaction. Kool-aid indeed.

  • davemills555

    If, after the political nature of the Citizen’s United ruling, you think our highest court rules with blind justice, you are a fool and you are hopelessly deluded. The Supreme Court today legislates from the bench. They did so in Citizen’s United and they will do it again with the Affordable Care Act. Most sane people understand that health care is a unique market, unlike any other, because it deals with life and death decisions. In any other market, if you choose not to participate, nobody else will pick up your slack. Not true with health care. With health care, the taxpayer is constantly being forced to pick up the slack for the uninsured. As long as such a unique market exists, the federal government has a right to regulate commerce in this unique market. I don’t expect to see certain members of the high court to rule with common sense. I expect that the same justices that crowned George W. Bush as Emperor of America will rule with the same political motives with regard to the Affordable Care Act.

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