HOW OBAMACARE'S SURVIVAL MAY ENHANCE UTILIZATION REVIEW DENIALS IN WORKERS COMPENSATION

Sections 10320 and 3403 of the Affordable Care Act (ACA) remain in force thanks to the calamitous Trump-Ryan campaign to repeal Obamacare in its entirety while omitting discussion whenever possible about aspects of the ACA where the Republicans would've been better off with debate and compromise. By not bringing the issue up independently, the Democrats joined hand-in-glove with their Republican opponents.

Sections 10320 and 3403 of the ACA enable a particularly harmful method of disallowing coverage of healthcare known as the Independent Payment Advisory Board (IPAB). The IPAB has often been linked to rationing of healthcare. Here's how it will work once it is installed as allowed by current ACA legislation.

The basic idea of the IPAB is to eliminate services from healthcare once it can be shown that such services are financial encumbrances to the program. In order to decide which diagnostic and treatment protocols qualify under this rubric, a special committee will be appointed. It will not be necessary to be a physician to get appointed, but it will be necessary to get a political appointment. The job is envisioned to pay about $165,000 per year. It will not be required for the committee to report to Congress which will happily divest itself of this controversial oversight. It is expected that the committee will be appointed in 2017 or 2018 or as soon as costs escalate beyond current levels.

An example is the restriction that Medicare recently imposed on cardiac pacemakers. The decision as to which patients should have pacemakers used to be up to one's cardiologist. No more. There is now an impediment, namely, Medicare itself. In the absence of specific findings mandated by administration authorities, pacemaker coverage can now be denied. Not the pacemaker itself, mind you, just its coverage under Medicare -- so, Dear Reader, if you are  among those whose concern about pacemakers is less than theoretical, here is the information you may need when the IPAB nixes your application: cardiac pacemakers cost about $6,000 on the open market. That does not include professional fees and other related costs.

This IPAB program has been called "rationing." It isn't rationing on a per se or individual basis. It is rationing across the board for entire classes of potential recipients. It's purpose is to stretch the ACA dollar since it is expected that the ACA's financial troubles will get worse sooner than expected given recent increases in policy costs and deductibles. This reasoning, cost reduction, is the same as California's approach to Utilization Review (UR) for Injured workers.

Injured workers on the wrong end of Utilization Review (UR) whose rejection of treatment is usually upheld by Independent Medical Review (IMR) will immediately recognize this technique as a denial of care mechanism. In a nutshell, Congress has now extended the ACA'S chief mechanism for "denial of care" and has managed to keep the public in the dark. No more! This writer urges all of us, injured worker or not, to make one's own legislator face this issue.

By way of recent history, the IPAB was initially aimed at Medicare's recipients -- it was called the IMAB (Independent Medicare Advisory Board) then. It got deleted from Medicare when thousands of Medicare recipients protested loudly enough for Congress to hear them.

My recommendation: whether or not one is an injured worker, but especially if one is an injured worker, the time to shout out for repeal of Sections 10320 and 3403 of the ACA has arrived.  This step can be taken without repeal of the entire ACA which would remain a separate issue.