Quality and The Affordable Care Act

There is a great deal written on President Obama’s health care – actually mostly insurance – reform, the Affordable Care Act (ACA), much of it driven by the ideology of the writer and / or the organization for whom the writer scribes.  I have contributed to this – in some small measure – myself; I am not sure that this is something of which I should be proud.

Asking why health reform didn’t go further, why we don’t have a single payor option, a socialized option, why so much emphasis is placed upon the private insurance companies, and so forth are all good and important questions.  But at this point, they are not entirely relevant. We have the ACA, it is law.  We now have to determine how we will make it work for our people.  Hence the title of this missive.

In the Past:

From 1979 through 1983 I was a member of the internal medicine house-staff at The Cook County Hospital (CCH), in Chicago.  (Chicago is where I learned that the winter does not end after December !  Great city as long as you are there only from May through November.)  During one of my rotations in the Emergency Department, the section nurse brought me the ED work sheet of a man who had presented with a complaint of “bloody urine”.  Doctor Layon, she said, here is your next patient.  So I go into the cubicle, introduce myself and ask this man what was happening.  He said, indeed, that he was having bloody urine.  After asking a few more questions, I requested permission to examine the man’s genitalia; he agreed and I pulled back the sheet and lifted up his hospital gown.

Imagine my surprise when I noted – astute clinician that I was at the time – that there was NO genitalia present.  The man’s penis and scrotum were gone, replaced by a fungating mass that represented, penile cancer.  Bloody urine indeed.  I admitted the man and soon lost track of him.  The nature of safety-net hospitals often results in that kind of care.  My suspicion is that he did not live long after he was diagnosed.

What has this to do with the ACA ?

The Answer Revolves Around the Number “50 Million”:

Former President GW Bush famously noted that there was no access problem in the American Health Care System.  That anyone could walk into any ED and be cared for (1).  And of course, as my example case above notes, this is sort of correct.  Yes, this man walked into the CCH ED.  Yes, we cared for him.  Yes, I am pretty sure he died rapidly.  Is this what we want from a health system ?

First of all, the number of ED beds is decreasing (see Reference # 1).  Secondly, as the Division Chief of Emergency Medicine at the University of Florida – Shands Hospital from 1995 through 1999 (how I became this is a story best told with a glass – actually several glasses – of good red wine) I have seen the way this system doesn’t work.

Anyone can walk into any ED and be seen.  If they have a life-threatening emergency, they will be cared for.  When they are sent out they may be given a number to call for follow-up care.

So the man with the penile cancer might have come to see us earlier in Chicago. We might have noted that there was a problem and given him a number to call for an appointment with one of our Urology colleagues.  He might or might not have gotten the appointment, depending upon whether or not he had funding (likely did not) and whether or not the funding was Medicaid (likely would have been).  This matters today because much of the expansion in access to health care called for in the ACA revolves around the issue of Medicaid funding.  Question is: Will this work ?

The answer is “Perhaps”

The ACA-driven expansion in Medicaid will indeed provide better access.  But is we add 45 to 50 million people to our health care system, and manage it the way we always have – that is procedural based with very little consideration given to quality – we will sink.

Hospitals are looking forward to the Medicaid expansion as there will be less un-reimbursed care; but the key is that quality must also increase or the increased funding will not cover the additional care (2).  The mantra of some governors that increasing Medicaid will break their budgets is most likely an exaggeration (3).

This is the / a key to expansion.  We provide a great deal of care, not all of which is needed or high quality.

Access and better quality care would likely have saved my patient’s life back the The County.  At least there is a chance of a better outcome.  Admittedly the ACA has many imperfections, but with the status quo, we are doomed.

The issue of quality and what it might actually mean will be the topic on my next piece.


1. http://www.dailykos.com/story/2011/05/18/977178/-Disappearing-Emergency-Rooms-Expose-GOP-Health-Care-Farce accessed 17 March, 2013

2. http://www.washingtonpost.com/blogs/wonkblog/wp/2012/07/03/why-hospitals-heart-the-medicaid-expansion-in-one-chart/ accessed 17 March, 2013

3. http://www.washingtonpost.com/blogs/wonkblog/wp/2012/07/03/the-truth-about-medicaids-cost-to-states-in-three-charts/ accessed 17 March, 2013

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About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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2 Responses to Quality and The Affordable Care Act

  1. Marcelle says:

    Are there any quality of care guidelines or recommendations on procedures (i.e. when certain procedures may or may not be necessary; I mean this is respect to reducing unnecessary although relevant procedures) that all healthcare institutions must follow? Is each institution responsible for determining it’s own guidelines for care?

    • AJ Layon says:

      Marcelle –
      I am not precisely clear as to the question yo are asking. There are generally accepted quality of care issues. For example, hospital acquired infections: ventilator associated pneumonia, central line associated blood stream infections, catheter associated urinary tract infections, Clostridium difficile associated diarrhea (CDAD). Others are related to process, such as Patient / Family Communication in the Intensive Care Unit. And there are others.

      Is this the question ?

      Or is it “From where do these quality metrics come ?” And the answer to that is from CMS (the Federal Centers for Medicare and Medicaid Services), The Joint Commission, The Institute for Health Care Improvement, and so forth.

      Let me know if this answers your query.

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