The announcement by the Centers for Medicaid and Medicare Services (CMS) to move 50% of its non-managed care spending into Accountable Care Organizations (ACOs) and bundled payments coupled with the recent passage of Medicare Access and CHIP Reauthorization Act (H.R.2) the repeal of the so called ‘doc fix’ will lead to the end of private healthcare, narrow the range of medical services offered by physicians, and increase the cost to patients and taxpayers.
It will not accomplish the goal of improvement of outcomes or increase access to healthcare for Americans. Instead, these changes will likely further decrease access for the sickest patients and decrease the quality of care for patients overall. If physicians and hospitals are now to be rewarded for positive outcomes, they will skew their services to healthier patients if for no other reason than to remain open. Under the ACO model members will receive a prescribed amount of money each year. The organization will access this ‘pot’ to deliver all medical services – tests, admissions, procedures and office visits. At the end of the year, members will share in the money left over. This model will inevitably put pressure on clinicians to avoid providing costly services and steer sicker patients to palliative care (hospice), and will most assuredly discourage doctors and hospitals from offering care that will be considered expensive. Doctors who work in this model will be in the business of acting as agents for a system that is driven by external dictates that place an artificial value on an individual and will destroy patient privacy. What was initially billed as a choice is now the law under H.R.2. It sounds good until it hits home when a patient needs the service that is denied because he/she is too old, too sick or otherwise is not deemed worthy because of a dire and/or costly diagnosis.
There are many truths about The Affordable Care Act that can no longer be denied: It is not affordable; it is not patient centered; it limits access to care; and it has not decreased medical costs. The one constant to date has been the pain inflicted as it continues to unfold. For those who think that the changes in our healthcare system are unintended, they only need to look at the law to figure out that the ACA is the final piece of a very large puzzle of a movement that has been relentless in its goal to move the US healthcare system into the larger centralized socialized global healthcare system where healthcare is delivered by committee and payments are doled out on the largess of the government – de facto single payer.
Coercive healthcare system based on pay-to-play
One of the casualties of this paradigm shift will be the heart of the American healthcare system – the independent physician. Over the past 10 years the number of physicians in private practice has decreased from two-thirds to one-third of practicing physicians. This decimation has been tied to government regulations such as the mandate of electronic medical records (HITECH), compliance mandates for privacy of medical information (HIPAA), and the ruthless and relentless move to decrease reimbursements to physicians. It has gotten so bad that only 17cents of the healthcare dollar is now spent on care given by physicians. The rest of the healthcare dollar goes to the pharmaceutical industry, hospitals, administrative fees generated by government and commercial insurance companies, and to trial lawyers caused by the practice of defensive medicine.
The control of reimbursements has led to a decrease in the scope of practice for specialists as well as a distance between the primary care physician and the patient. For example, the time a physician spends with the individual patient has decreased to seven minutes and the front line of care has shifted to allied healthcare professionals. Unfortunately, the physician has been used as the fall guy for what’s wrong with our healthcare system, when in fact he/she has had the least power over the business and now has lost the power over the practice of medicine.
These changes have been touted as a win for ObamaCare. Proponents have stated that the law is working because it is lowering healthcare costs. However, this meme has ignored the increase in prohibitive out-of-pocket costs to patients, their increased difficulty in being able to have access to physicians, a the limit in their access to treatment due to a decrease in covered services and medications, and in increase in costs to tax payers. With the passage of The H.R.2, reimbursements have been tied to the delivery of ‘value-based’ care and there is no limit to this trend. Doctors will be conscripted into this system using the yoke of Maintenance of Certification (MOC), a lucrative and questionable scheme initiated by the American Board of Specialties (AMBS) to coerce physician members to take expensive arbitrary tests in order to maintain their Board certification forcing doctors to pay to continue to practice medicine.
If you like your doctor you can keep your doctor
There is a less well understood aspect of Obamacare which will become obvious as the law continues to be implemented. It will be the end of the independent private physician. The days of the solo practitioner and small group practice are numbered. In the shift towards empowering the healthcare team in the form of ACOs, the role of the physician has been decreased to one of an administrator for the most part. Clinically, the doctor has become interchangeable with physician extenders. In an effort to save money and to implement a system driven by algorithms and one-size-fits-all medicine, the front line of medicine has increasingly been taken over by other allied healthcare professionals. There has been a concerted effort to devalue the doctor. Medical education has shifted to a doctor being part of the healthcare team which uses central guidelines and population based Evidence-Based medicine instead of clinical judgment based on individualized patient care. Instead of having the power to make clinical decisions and lead the planning of patient care, the doctor has been relegated to the administrative task of signing off on clinical notes and writing prescriptions. One only needs to look at the electronic medical record to figure out how removed doctors have become from front-line patient care. The nursing profession has also been a casualty of these changes. They are no longer on the front line of patient care, they have also become part of the administrative process. Registered Nurses with the most experience have increasingly become case managers which are in essence compliance officers tasked with making sure that documentation is in place to ensure that the hospitals get paid by Medicare and commercial insurance companies.
The Electronic Medical Record
In the past, the doctor was involved with the patient visit from the first moment the patient entered the exam room. The physician personally entered all of the information about the patient in real-time and examined the patient. This valuable interaction allowed for subtle information to be used in forming a plan and was vital to inculcating a positive doctor-patient relationship. Now the typical “flow” of the patient visit starts with the medical assistant who takes the patient information and logs into the electronic medical record (EMR) all of the patient history, vitals, medications used, allergies etc. Most of the visit is taken up with inputting information most the time without even looking at the patient. It is all about checking the box and moving on in order to close the section of the chart. If the practice also has a nurse practitioner or a physician assistant they perform the physical examination and produce the treatment plan. The physician then will sign off on the chart and approve the plan and medications prescribed. With current and ever-expanding government mandates a great deal of the chart is spent on filling in the Meaningful Use (MU) section which asks in-depth personal questions such as – have you ever tried to hurt yourself, vaccination history, whether or not you feel depressed, how many people live in the household, and whether there are guns in the home all designed to gather personal information which can potentially be shared. This comprehensive personal history is mandatory for Medicare providers. And for those who think that there is an option to skip over these questions, it is important to realize that the setup of the EMR does not allow the physician to close the chart until these questions have been completed, effectively mandating that the questions be asked and answered.
The toll on the physician – the rise of the Provider
The practice of medicine has changed dramatically over the past 10 years. The joy of practicing individualized medicine with autonomy has given way to apathy, a decrease in the morale, a loss of collegiality, and a mentality of go along to get along with physicians either biding their time until they can either retire, or completely submitting to a system that pits the doctor against the patient; thereby, making them part of a system that is designed to capture patient information, to control access and eventually to control outcome where “value based” medicine is determined by actuaries and government officials. The physician and nurse relationship has devolved from a collegial relationship with patient care as its center into one where the nurse makes sure that the doctor inputs the proper information to reconcile the chart so that reimbursements to the hospital will not be disrupted.
The future of medicine is about choice
Patients and physicians need to make a decision whether to be a part of this system. As the foundation of our healthcare system, both need to determine whether they want to decide their value or will they have it decided for them. For physicians that may mean opting out not only of Medicare and Medicaid but commercial insurance altogether; and for patients that may mean deciding that they are worthy of receiving care from a physician who is their advocate and not an agent for the government.
Freedom of choice is the essence of quality healthcare. Its power emanates from the individual. Choosing to go to an independent physician who offers transparent pricing (in the form of direct pay, sliding scale fees or a membership model); choosing free standing urgent care facilities, instead of emergency rooms for routine care, choosing independent surgery centers (The Surgery Center of Oklahoma) instead of the hospital; choosing medical cost-sharing (www.libertyoncall.org) as a way of paying for medical services instead of commercial medical insurance; and adding supplemental policies such as AFLAC or Mutual of Omaha to help cover routine and catastrophic healthcare needs will give the patient the ability to both take their power back, and have an affordable way to finally get what they actually pay for. Those physicians who choose to take their power back will empower an alternative system where they can stop being ‘providers’ and once again have the freedom to love being a doctor. Furthermore, patients who want to have the freedom to take personal responsibility will be rewarded with affordable high quality healthcare which is based on their well-being.