This is second of two columns reporting on Dr. John Roberts' presentation at the April 1 Lunch with the League on the Affordable Health Care Act. The first column dealt with the seriousness and challenges of financing our health care system. This column speaks to some of the details contained in the legislation.

The Patient Protection and Accountable Care Act (aka "Obamacare") was approved March 23, 2010. Of the more than 1300 pages, Dr. Roberts centered on Title III "Improving the Quality and Efficiency of Health Care", Title IV "Prevention of Chronic Disease and Improving Public Health" and Title VI "Transparency and Program Integrity" dealing with sections related to physician ownership, other transparency and patient-centered outcomes research.

The mission of the Patient Centered Outcomes Research Institute (PCORI) is the design and evaluation of comparative effectiveness research studies to measure OUTCOMES that will be used to make care recommendations to Medicare. PCORI is private, independent, not-for-profit organization overseen by an appointed Board of Governors. This board of 19 members includes patients, physicians, nurses, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts.

PCORI works along with the Agency for Healthcare Research & Quality (AHRQ) and the National Institutes of Health (NIH), one of the world's foremost medical research centers. The law forbids PCORI from developing or employing a "dollars per quality adjusted life year" as a threshold to establish what type of healthcare is cost effective or recommended.

The Independent Payment Advisory Board (IPAB) has been referred to as the "death panel" by some. But IPAB mandate is to achieve Medicare savings without affecting quality or coverage. It cannot recommend rationing, raising revenues, premiums or cost sharing and can't restrict benefits or modify eligibility criteria. IPAB takes power away from Congress and special interests by utilizing those knowledgeable in health care policy.

IPAB has 15 members appointed by the president in consultation with Senate majority & minority leaders, Speaker of the House & Minority Leader of the House, subject to Senate confirmation. The Board only convenes if Medicare spending exceeds the Centers for Medicare and Medicaid Services (CMS) target. IPAB makes spending cut recommendations to the Senate. It takes a 3/5 Senate supermajority to reject recommendations. If rejected, the Senate must find alternative cuts to achieve the same savings.

Some of the challenges for your doctor are: standardized treatment guidelines (cookbook medicine?), linking payment to quality outcomes, and what to do with non-compliant patients.

Medicare shared savings programs include Accountable Care Organizations (ACO) which provide coordinated care and chronic disease management while lowering costs; Electronic Health Record (EHR), adherence to recommended treatment guidelines, and data reporting/mining for quality improvement.

Medical Society has a number of recommendations such as the "Choosing Wisely"® initiative ( which identifies things physicians and patients should question. Others recommendations are the American Board of Internal Medicine initiative, and nine additional specialty societies including the American Academy of Family Physicians (AAFP) and Consumer Reports.

Dr. Roberts concluded by stressing we need to reduce the enormous spending amounts on healthcare and noted the deployment of the Accountable Care Organization model will be an important test of medicine in practice. "Demanding evidence of value in medicine does not have to be at odds with the values of medical humanism."

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