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Sunday, May 30, 2010

The immediate effects of health care reform

This could be a very short blog. Health care reform passed and we are simply waiting for something to happen. Nothing substantial has happened yet. We are anxiously waiting to see if the SGR fix goes through and concerned about the effects if we see a 21% hit on MD payments from Medicare. Such a cut will be impactful to say the least. However, this has little to do with the Patient Protection and Affordable Care Act of 2010. According to Wikipedia, the following elements went into effect immediately after President Obama signed the bill:

The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.[30] 
The Medicaid drug rebate for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.[30] 
Support Comparative Effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute.[30] 
Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.[30]
The Indian Health Care Improvement Act is reauthorized and amended.[30]

What has the average American noticed thus far? Absolutely nothing! When will the average Joe or Jane actually notice something which is a direct consequence of the legislation? That is not clear to me. There are a few stipulations which will be enacted over the next year which will require insurers to spend 85% of premium dollars on actual "health care", a completely unenforceable requirement since no one can really define what that is. Insurers are already hard at work redefining what this actually means and you can be assured that legions of nurses and doctors on the insurers payroll will have their tasks redefined from the administrative to care realms. When these are enacted, what will we notice? Not much I suspect.

Most of the meaty elements of the bill do not go into effect until 2014 and many do go into effect until 2017 or 2018, The pundits are debating in earnest what the effects of this bill will be. They can only guess and the sad truth is there is no way that we can ever determine whether events happening a decade from today (positive or negative) will be linked causally to the legislation drafted and passed this year. We cannot hold anyone or anything accountable when the actions and the consequences are separated by such a time span.

I understand why we have a fascination with sports, games, and music. I can go to a golf driving range and get a bucket of balls to hit. I may be dismal but I can get immediate feedback from making adjustments and trying again. I know when I am doing things right and when I have it all wrong and I know it almost immediately. The same is true of playing a musical instrument or playing video games. We are wired to respond to feedback and to understand these feedback time frames. If we do something which does not further our ends, we quickly realize this and generally cease activities which do not accomplish our goals. This is particularly true if the actions result in harm or physical discomfort.

If the feedback time frame is delayed, many humans get into trouble. The most obvious examples are those involving addictive substances or behaviors. The immediate effects may be pleasant and the dire consequences delayed days, weeks, or years. This is a recipe for disaster. When the timeline for assessing consequences of legislative and legal interventions extends to generations, we are essentially toast. I have my doubts that the current health care legislation will accomplish anything it has set out to do. By the time that the key provisions are actually enacted and sufficient time has passed to make an assessment of actual success or failure, we will have forgotten why various provisions were enacted and likely have modified many elements based upon political expediency. We will have no reference points, no control groups, and those in power will share scant resemblance to those who passed the legislation in the first place.

A major problem with entrusting political entities with solving problems is that the feedback loops involved are so dismal. It is not like shooting a basketball or playing the piano where you know you have missed the foul shot or hit the wrong keys. When political entities effect changes, we virtually never know if we got it right. There are no gold standards and the time frames required to assess the wisdom of interventions is beyond even the most focused and enlightened human attention span. Present decisions are virtually always driven by short term political expediency.If present decisions, driven by such short term motivations, happen to be wise long term interventions, it is simply dumb luck. The question arises.. Why entrust entities and institutions which are inherently unaccountable with such responsibility?

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