The State Of Health Care In The US of A
|Consolidation and Big Is The Government Plan
Well here we are in 2016 and despite how drastically the federal government has disrupted our health care market, neither party is ready to discuss the fall out. To refresh everyone's memory, Obamacare (currently known as ACA and prior to that PPACA) legislation has made it a requirement that all US citizen's buy health insurance from cradle to grave. In the process of this mandate many sources of subsidy (payment provided from the collective) were created and one of the more obvious was
cutting 740 billion dollars from Medicare.
That was money US citizen's paid in for Medicare services, moved/confiscated to fund the Patient Protection and Affordable Care Act (PPACA), now the Affordable Care Act (ACA)
Seeing what was coming and anticipating even more heinous high crimes and misdemeanors, I decided to end my career-long partnerships in order to maintain the primary premise of my Hippocratic oath- to hold the patient as the highest goal in the practice of medicine.
By going into private, solo practice I am allowed to make hard and rapid decisions as the socialization and overtake of the patient doctor relationship goes into full onslaught mode. Not all of us (in fact the majority of us) wish to give up our right to engage in commerce and seek the best health care at the best price. As a physician I am not willing to compromise my ethical obligation to my patients by allowing a 3rd party payer to dictate how we get the job done.
So let's look at the health care landscape we are presently experiencing. Our community is a microcosm of what is happening across the country, especially urban areas.
Due to Price-Fixing, the system is favoring pricing towards hospital systems. Private physician businesses are folding left and right.
We have moved from nearly 80 % private doctor practice ownership to under 30% in one decade! In exchange for this the sold practices are subsidized from the extra money funneled to the hospitals conglomerates- now your doctors are working for the hospitals and not for you.
The biggest sub specialty decimated in the past 8 years from this price-rigging apparatus has been cardiology. Diagnostic radiology has also been selected to be squeezed out of the market. Without private practice diagnostic facilities your private doctors will be further weakened, they hope to see the last stragglers come in off the range when this domino falls!
No physician evaluation service has been rewarded with improved reimbursement yet the requirements for data collection and entry from your doctor by the "powers-that-be" have resulted in at least a 30% reduction in efficiency for seeing patients. Your primary care doctors (Internal Medicine and Family Medicine) can't make a break even business arrangement due to the added and increasing overhead. All new physicians's being hired in the market are hospital salaried and the fastest expanding group are Hospitalists. These doctors don't have a patient community outside of someone in a hospital patient bed.
Our current hospital system, recently renamed Lee Memorial Health just this January created a closed Hospitalist Network. Your doctors in the hospital are now effectively employed by the hospital. It is my understanding that these hired doctors have to sign "no compete" clauses as part of their employment contract. This means that if they chose to leave their present employment arrangement they will have to leave the community if they wish to practice medicine. Terrific news right?
Meanwhile back at the ranch, the insurance companies are cutting private practice and outpatient (non-hospital owned) reimbursement in order to pay for the now "fully-in-control" consolidated entities like the hospital systems. They seem to be in cahoots with the consolidation plan.
Now to the final contributor to this whole mess- the good old Federal Government. It appears they have been convinced by the US Hospital Lobby, the Insurance lobby and perhaps less obviously the Health Care Academics lobby that we want this consolidated model. The latest "fix to the SGR crisis" was a legislated bipartisan act called MACRA-
Medicare Access and CHIP Reauthorization Act. This law is a 5 year plan (now 2 years into enactment) to put all the Medicare patients into a model of payment and care called Accountable Care Organizations (ACO's). This is a replicated payment scheme which was tried and failed during the First Clinton administration where they tried to put everyone into a Health Maintenance Organization (HMO). HMO's failed miserably because the average American wouldn't stand for being treated like cattle when it comes their health care.
Doctors are being coerced to put their patients' into an ACO model (it doesn't require your consent as a patient). This model provides for bonuses as well as penalties if the doctor's panel of Medicare patients doesn't or does cost more in health care dollars then the average patient utilization and the past historical year of cost. They are going to have to collect all resource utilization data on their patients and prove to Uncle Sam they are cost effective doctors. I hope folks can see how this will create conflicts of interest regarding providing individual patients the best treatment plan and service.
Following are a few other items embedded in the MACRA legislation. The rules for this law now exceed 900 pages:
- Mandated regulatory changes adding to practice overhead- with no ability to change office prices for Medicare patients unless the doctor quits Medicare. If a doctor quits Medicare, patients then can't get any reimbursement for services paid for in the doctors office.
- Future penalties to practices that fail to comply with regulatory requirements starting in 2014.
- Due to regulated price policies difficulty in getting patients referrals/access and even medications. We have been having shortages of even the most basic IV fluids. Most recently reimbursement for treating osteoporosis with IV infusion once a year is below what it cost to get the drug.
- The New 2014 MACRA law is extending price-fixing an additional 5 years with plans to "restructure" physician and practice payment method- all while mandating further "to yet be defined" quality measure requirements and additional regulatory and bureaucratic policies. Who will be policing this is also to be determined.
Upon reviewing what has happened historically as well as what is planned for the future of especially Medicare patients, I hope my readers can appreciate how important the upcoming election is. Mrs. Clinton was behind the 90's HMO failed policy and as stated the ACO model is the same pig with different lipstick. What the system and the people of this country seem not to fully appreciate is how by regulating and price-fixing health care as well as designing archaic models of care we are going into a major backwards mode. I will continue to try to convince people that the federal government's solution to the health care market is totally misguided as well as misrepresented from the patient's point of view.