Obamacare “Divide and Conquer” Strategy?

May 13, 2015

 
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America’s largest health insurer is buying a national chain of urgent care clinics. Optum, a subsidiary of UnitedHealth Group, the largest health insurer in the United States, is purchasing MedExpress, which “operates 141 neighborhood medical centers in 11 states.” What does it mean if your doctor, clinic and insurer have joined camps?

 
It means the proverbial fox is guarding the hen house…and you’re the hen.
 
Such consolidation creates a troubling conflict of interest. The doctor is no longer fully biased toward patients. The doctor is employed by and dependent on an insurer-owner. For patients covered by the insurer-owner of the clinic, they may unfortunately find themselves viewed by the clinic as a financial risk.
 
Is this part of a broader “divide and conquer” strategy? Obamacare developed Accountable Care Organizations (ACOs) to facilitate – indeed, embed – a divisive consolidation of hospitals, doctors, government and insurers to ration care, starting with Medicare. Section 3022 called “Medicare Shared Savings Program,” establishes ACOs, which some call “HMOs on steroids.” (See ACO growth chart below.)
 
Health Affairs explains, “In an ACO, health care providers accept responsibility for the cost and quality of care for a defined population.” Thus, the doctor, the clinic and the hospital join together to actually become the insurer, responsible for the cost of patient care. For patients this is a hazard waiting to happen.
 
If patients and doctors are pitted against each other because the doctor is employed by the patient’s insurer, the patient, already in a vulnerable state simply by being a patient, is more vulnerable than ever. Furthermore, if the patient has paid thousands of dollars to a third-party payer (insurer) to cover medical expenses, the patient has fewer funds to buy the care they need if the insurer-employed doctor withholds that care.
 
So the questions are obvious. If as ACOs, health care providers (doctors and hospitals) are becoming insurers by taking on the financial risk of patient care, why wouldn’t today’s insurers, like UnitedHealth Group, become providers? And where does that leave the patient?
 
Patients will still receive treatment, but there will be pressure to restrict access. From the large corporate perspective, the patient is essentially the legal pretense enabling this massive consolidation and redistribution of power and dollars to insurer-providers and ACO provider-insurers.
 
There will be pressure to ration. ACOs that “save” money share the savings with the federal government. The less the ACO spends on patient care, the more they get to keep. Thus, Obamacare requires:
 
‘‘(3) MONITORING AVOIDANCE OF AT-RISK PATIENTS.—If the Secretary determines that an ACO has taken steps to avoid patients at risk in order to reduce the likelihood of increasing costs to the ACO the Secretary may impose an appropriate sanction on the ACO, including termination from the program.
 
But legal language cannot protect patients. Since most patients no longer manage their own health care dollars – and because the ACA handed over the entire health care system to managed care plans (which the U.S. Supreme Court ruled in Pegram vs. Herdrich were established by Congress to ration care) – the patient remains at risk.
 
We need a “Wedge of Freedom” for health care – a protective, expandable legal space where doctors and patients are free to work together without government and third-party interference, where longstanding medical ethics abide, cash for care transactions are protected, privacy is paramount, charitable hospitals are resurrected, and pocketbook prices are possible. If we build it, they will come – in ever increasing numbers.
 
Joining with you to build the Wedge,
 
Twila Brase, RN, PHN
President and Co-founder
 
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