By Paul Goldfinger, MD, FACC
Now that the ACA has become a certain reality, the two areas that interest me most should begin to come into focus out of the mist. One has to do with how the quality and availability of healthcare will be affected, while the second is about how the practice of medicine by physicians will change.
The evolution of all this will start out slowly and then become an avalanche over the next five years as new regulations come into play. At this time, there is no way to be certain about much of the details, because the ACA is, in large part, largely a skeletal plan waiting for the blanks to be filled in. There are many complicated aspects to all this, so let’s get specific: What will happen to physicians and the doctor-patient relationship?
It is clear that there will not be enough doctors to meet the needs of all the patients who will have health insurance. Care will be given by teams of providers, supervised by doctors who will delegate tasks to all sorts of physician extenders like nurses, technicians and PA’s. Doctors will no longer have a personal relationship with patients. Care will be largely governed by practice guidelines, and physicians will become cogs in industrial-size health systems. Most doctors will eventually become employees on salary; fee for service reimbursements will disappear as will the private practice of medicine by solo or small group practices.
Here are examples of the unsettling current climate that I have observed recently by talking to three physicians.
Doctor A is a solo internist who has been in practice for about 10 years. He is 42 years old and he is loved by his patients and highly regarded by his colleagues. He has just announced that he will soon close his practice and seek work in some type of large-scale setting like the VA, the military, or within a hospital-run mega-organization. The reason is economic: declining reimbursements and rising costs have caused his “business” to fail.
Doctor B is a 52-year-old cardiologist who is a superb and caring clinician who is consistently mentioned in the “best doctor” rankings. His current practice hours are long and exhausting. He and his colleagues have formed a defensive alliance — a large group practice with other cardiologists — but he cannot keep up with the rising demand for his services accompanied by sharp declines in reimbursements (especially from Medicare) and by rising costs. Recently he stopped taking new patients, and his group had to fire some excellent employees.
Doctor B says that morale is low among his colleagues because they see no way to pedal faster while maintaining quality and income. He tells me that I “got out just in time,” and he is glad to be in the final phase of his practice.
Doctor C is a 3rd year internal medicine resident at a city medical center. He tells me that half of his fellow residents will go on to become specialists. Another quarter are seeking salaried hospital jobs. Those “hospitalists” work 7 days on and 7 days off. The final 25% are seeking jobs in outpatient settings, but almost none of them are planning to open their own practice. He and his fellow residents expect decent pay in exchange for a better life style. Doctor C is satisfied with that conclusion. The new doctors coming out will learn to be comfortable with all the changes that the ACA will bring. They won’t miss a style of medicine that they will never experience.
Most practicing doctors today are feeling discouraged about the prospects for their profession. They see the ACA as destroying a system that could be improved but should not be changed wholesale, as will occur under the ACA. About 55% of physicians said that they would vote for Romney, vs. 36% for Obama.
Stay tuned.
Reblogged this on Blogfinger and commented:
I thought you might like to read my predictions put forth six years ago. It looks like I was on target, and in some ways, things are getting worse. Paul Goldfinger, MD (Having got out in time, I am now a Blogger, on the cutting edge of small town communication.)
Please look at the comments . The discussion is very good. Too bad that Ken Buckley left the playing field to hang out with the moribund HOA on the bench.
Paul,
After watching the Sunday night program “60 Mimutes” I feel you you may have to raise anew the role of the physician in controling healthcare costs. Interviewed doctors who worked at HMA hospitals who were held to meet admissions goals of 20% for emergency room patients and 50% for those 65 and older (Medicare pays for them). Those who did not comply and did the “right thing” were fired or moved to other positions.
Re: Go West:
This excellent comment belongs with ACA discussion. It illustrates results over time, not pie in the sky conjectures.
Having lived on both the East and West Coasts we have experienced a very different approach to health care. In the East the main providers seems to be mainly “private physicians” whereas in the West the main providers are HMO type, Kaiser, John Muir, etc.
We live in CA and have been very pleased with the HMO’s, Kaiser in particular where all of your health records are centrally maintained. It’s a very efficient and professionally run organization. Doctors are employees which is a big difference from our experience in the East where independent doctors seem to be mostly focused on “return on investment”.
Realist: Thank you for some good ideas. As far as rewarding lawyers is concerned, here is good news: Some law schools are cutting back on the size of their entering classes because there is a glut of lawyers.
Regarding buying insurance out of state, the ACA is set up with each state having an insurance exchange. If a state refuses to set one up, then the federal government will do it for them. The insurance exchange program is scheduled to begin in January 2014, but the setting-up process has already begun.
Here’s a little known fact that might impact some of you: Starting in January 2013, the income tax deduction threshold for medical expenses rises from 7.5% of income to 10%. So much for taxing only the rich.
My concern with the future of health care is reflected in the Federal Flood Insurance program. Basically private insurance wouldn’t cover certain flood areas because it wasn’t worth the risk or they couldn’t reduce their risk sufficiently to make it a viable business venture. So people didn’t have coverage and the federal government stepped in and provided it. So now we have people living in areas they never lived before (LBI)
Instead of covering everyone regardless of risk, the government needs to tell people No. You can’t live one hundred feet from an ocean. You can’t smoke, eat and weigh four hundred pounds. If people do, then they should pay for the extra coverage.
Doctors need to know that they have protection for acting in good faith. Medicine isn’t magic, it’s not perfect and sometimes bad things happen. Doctors need to know they won’t lose their shirt if something doesn’t work
Ken, here are some suggestions. 1) allow purchase of health insurance across state lines. More competition generates innovation and lower costs. 2) as much as I endorse free market, I am enough of a realist to acknowledge free market does not handle catastrophic illness well. Allow the gov’t to handle insurance for catastrophic illness (sort of like a FEMA for health) while health insurance handles more standard issues. Not only does it lower costs, but it opens the market to smaller insurance companies and lets larger businesses self insure if appropriate. 3) tort reform. Let’s punish bad doctors– not reward bad lawyers. 4) national health database. Let doctors printout health histories rather then waste time getting incomplete oral histories. Might also prevent duplicate tests and conflicting medicines. 5) encourage intelligent and open minded dialogue. Oops, Blogfinger already did that.
I believe the ACA has an underlying goal which is to do away with these insurance companies and wind up with one government operated “single payer” insurance system. This could turn out to be the best solution, but the devil is in the details, and better ideas may emerge.
Our current healthcare system is based on insurance companies paying for most medical care. All the comments indicate big problems. It is not the doctors, ER workers, the poor, et al, that are the problem. It is the current system.
Any solutions to the insurance companies doing such a lousy job?
You are seeing it already. Go into any ER, JSUMC, JFK in Edison, Perth Amboy, ect. At any given time you might have 1 or 2 physicians working and covering up to 30 beds, plus the triage area. Pediatrics might have 1 on for 10 beds. The rest are PA’s who do the heavy lifting. If you get sent to Prompt/Quick/Express care you will most likely be treated by a PA and never see a physician.
I see very smart people who start in the healthcare field and the majority are moving towards a PA degree. The pay is slightly less, but most work on a physician’s malpractice insurance and carry a smaller policy on themselves. So the trade off is lower pay but less expensive malpractice.
Why would a student want to pursue a MD/DO when he can go for a PA and get paid nearly the same, do 99% of the “cool” stuff, and pay less in insurance every year?
How will ACA address this trend? You can’t force people to become MD/DO and you can’t force them to stay in private practice. Will hospitals begin to accept the role as primary care providers? Meridian has built that clinic on W. Lake which is a step in that direction, but will that become the model?— a handful of mega-services that absorb not just a large number of hospitals but all the fringe services?
Meridian currently operates 5 hospitals, dialysis centers, occupational health centers, clinics, dentistry offices, OBGYN services, AIDS/HIV treatment centers ect. Will this state just become Meridian, AtlanticCare, Virtua, Capital Heath, and St Barnabas? How does that solve the problem? So we traded giant health insurance conglomerates for giant health care conglomerates?
We have had some discussions under my post that have strayed far afield from my original goal of discussing how physicians will fare under the ACA. But to address a few points that have been made.
1. Unless someone understands the triage system at work in ER’s, one might misinterpret what goes on there. It is not single file. It is risk based. I have worked in numerous hospitals with different demographics, but almost always, except in the military hospitals, the poor predominate in the ER. It’s because of the nature of our current system. But it is not a value of American medicine to treat the rich before the poor or to deny anyone care under emergency conditions.
I don’t think Charles was saying that the poor are the last to be seen in an ER or that they are refused care because of economic reasons or lack of insurance. He was bemoaning the fact that having no health insurance leaves the poor with no place to go but the ER, and there the experience tends to be horrible with long waits. He also correctly points out that individuals without health insurance do not get proper preventive care and are thus more vulnerable to serious complications. Under the ACA, nearly everyone will eventually have insurance coverage.
Our current system is flawed and needs to be fixed. The ACA is the only plan that was presented and passed by our democratic process, so that is the one we will have. That doesn’t mean that it should be immune to constructive criticism or change.
2. The doctor shortage is and will be a reality. Even if no doctor retires early or changes his job, there will still be a problem. Doctors have a right, like anybody else, to choose what is best for themselves and their families. To say that doctors should not “withhold their skills from society” is to assume that they have some unique obligation to society in terms of their work lives, but their freedoms of choice are no different than for other important professionals in our country including engineers, scientists, teachers, nurses, dentists, pharmacists, airline pilots, etc.
3. As for the growing role of physician assistants, nurse practitioners and doctor-nurses, I will refrain from commenting at this time.
Please don’t distort my words. It isn’t about the quality of ER workers, or that they’re out to punish their patients. It’s about the fact that so many people don’t have health coverage and therefore have to go sit in an ER for most any kind of medical attention — either that or go without medical attention, which many choose to do. When millions don’t have coverage this is what results, and it’s a system that’s plainly unfair to millions of Americans. I have seen this with my own eyes. I expect your overworked friends in ERs have seen it too. Ask them.
Charles, I know several ER workers and to imply that the quality or order of treatment is based on economics is a lie that borders on libel and if you have evidence otherwise, please bring it forward. ER workers are usually the lowest paid in the hospital, work the worst hours under the highest stress. You owe them an apology. If it appears the poorest wait the longest it is because they are more likely to use the ER as their primary care doctor and, because ERs use a triage system. Someone waiting to see a doctor for a minor ailment will wait the longest. It is not to punish the poor but to save the lives of the most medically needy.
Also, just because someone is against “Obamacare” does not mean they believe the current system works or that certain people don’t deserve proper medical care. I believe in proper medical care for everyone. However I believe the problem is a cost problem and a properly run system would lower cost to the point where 90%, rather then 75%, could afford health insurance. Then it would be much easier, and cheaper, for the government to assist the last 10% with less pressure to compromise quality. We have the same goal, just different approaches.
It is absolutely not a lie. I have hung out in ERs at all hours, including late at night. Late at night is when poor people often show up, and unless the situation is an emergency they are often made to sit and wait for many hours. If you have a day job, and your only way of getting care is this way, you have a very strong incentive not to go to the ER at all, but to stay home, try to get a night’s sleep and tough it out. Add in the fact that it isn’t always easy for these people to get transportation to an ER. They may have to arrange for child care as well. For such reasons, poor people with no insurance very often wait until symptoms are quite serious. They don’t get diagnosed early enough, they don’t get preventive treatment. I know what I’m talking about. A system that rations health care on the basis of a patient’s economic status is a callous system.
Twice the statement has been my made that those without insurance don’t or won’t get medical care when they need it. This is not true, it’s a plain lie. If you need medical care because your life is at stake and you present at an ER you are guaranteed medical care to save your life.
One of the models that I love is the Germanic model. In their system doctors work the ambulance and begin treatment in the field. Even here in America some agencies are using paramedics to make house calls and check on patients who have been identified as needing assistance taking medications ect. Acting as a home health aid but who is trained in emergency care and can recognize when a patient has deteriorated. They at under the guidance of a physician who supervises a group. Perhaps this is the new role for physicians? One physician directing a group of PA/RN/Paramedic both in and out of the hospital.
But the millions of people who can’t afford coverage already have trouble seeing the doctor of their choice. Serious trouble. They postpone care until there’s a crisis, and then they land in the ER.
If we’re going to have more patients in the future, we obviously do need more doctors for those patients. We need to find a way to train more to meet the heavier demand. The answer to this problem can’t be to continue to exclude those who can’t afford coverage, which is how the current system works. I really don’t want to live in a society where people with money get medical treatment and people without money can’t.
If doctors really are anticipating that there soon won’t be enough medical care to go around, and if their response to that problem is to quit their practice and withhold their skills from society, what does that say?
Charles: There is nothing in the ACA which directly restricts access to the doctor of your choice (as occurred in the 1980’s with the HMO’s.) However, you may have trouble seeing the doctor of your choice because he may have left practice.
In a recent survey, a significant number of doctors said they would consider retiring early or finding some institutional work because of the “promise” of the ACA which is worrying many physicians.
Another factor that might limit the choice of doctors will be when the numbers of physicians become inadequate at the time when the numbers of patients increase, resulting in a perfect storm of shortcuts and compromises that will affect your choice of doctors and your doctor’s choices.
I don’t think anything in the new law restricts an individual’s choice of physician. I would certainly be opposed to that
Charles, I appreciate your honesty. But just because you prefer someone else to choose for you is not justification for taking that right from me. I have problems picking wine, it doesn’t mean the government should choice wine for everyone. If you can pick a car mechanic, you can pick a primary physician.
I would rather be boiled in oil than have to shop around in an unstructured, unregulated market for the right health insurance, let alone for the right MRI, the right bone marrow transplant or the right CT scan. (It’s hard enough just choosing the right physician, particularly when you need a specialist.) Like most people, I just don’t have the information to judge such things, and I don’t have the time to acquire the information.
I don’t mind choosing which refrigerator or guitar or automobile to buy — that can be kind of fun — but in a field as complex and intimidating as health care I need the kind of structure that only the government can provide, and which I assume Obamacare will provide. Medicare provides such a structure for people seeking a supplemental policy — it provides a set of standardized requirements — and I really appreciate that.
When a politician tells me the American people are capable of choosing for themselves, I always think, “No, we’re not, not in this case.” Having a few options to choose from is satisfying. Having an endless, ever-changing array is a nightmare. It is also a con man’s dream.
Realist: The closest thing that will occur would be the insurance exchanges which will let you choose a plan that you like, but all the companies that take part in the exchanges have to offer the minimal requirements mandated by the government.
Whether you will be able to shop for the cheapest MRI—wait and see what the ACA has in store for you. If you have any information along those lines, please share them with us.
Ken: I disagree. If our goal is accessible high quality healthcare for all, and if that goal is unachievable, then it is the compromises which will define the success of the plan.
Paul,
It is not the many compromises that will be discovered, rather it is which ones will be actually implemented
Some say the free market is not appropriate for providing health care. I say we have moved away from the free market model and it has hurt us. Very few shop for their own health insurance. Because we require employers to provide health insurance, we have little say in our insurance.
Also, pricing of medical procedures is a mystery. Why shouldn’t I be allowed to shop for the cheapest MRI study? I should be able to reward medical providers who offer quality service at a reasonable price but I don’t know how much they charge and my insurance pays the majority of the bill.
Very few people have dental insurance and pay out of pocket. My dentist is much more influenced, and provides a much better service, then the doctors who are payed through insurance and government programs. By shopping around for car insurance and home owners insurance, I put pressure on those industries to provide the best service at a reasonable price. I am unable to do the same for my health insurance and my medical procedures.
Ken: I like your concise summary, but your buggy whip analogy is wrong, because no matter what happens in healthcare, the commodity which doctors produce remains the same: expert care for patients.
I think the crux of the matter has been unsaid: What everyone wants is high quality accessible healthcare for all. But the cost of that goal is prohibitive for most countries including ours.
If you look at healthcare for all in Europe and Canada, you will see that there are many compromises. What compromises will we discover when we seek quality care under the ACA?
Healthcare. A problem for all of us. Expensive…not much agreement on how to control that. Rationing?… unacceptable on its face…”death squads!”, long waits for procedures, etc…. but I do not hear sensible alternatives proposed. Insurance Companies paying the bills….how is that working for you? Wierd that we tolerate a business that charges (a lot) to pay bills and fights like hell when it is time to pay. A “one-payer” is so obvious but doesn’t have a chance….can ‘t you just hear the Insurance Industry SCREAMING (into the ears of their congressmen).. Cost? A seperate fee for each service instead of one fee for what ails you. Who came up with that business model? And the physians…times change, ask the steelworkers about changing times, could the buggy whip maker imagine what effect that combustion engine device was going have on his career? Can you remember the last time you got your news from a newspaper?
We have a big, expensive problem that will require lots and lots of new solutions and many, many changes that will make almost everybody unhappy.
Health Care Consumer: If you read my piece carefully, you will see that I do not blame the ACA for what is now happening to those three doctors. I described their situations as examples of the “unsettling current climate” in healthcare. I made it clear that the ACA is only now in its very beginnings of being implemented.
I did try to predict, in general terms, what some of the effects of the ACA will be in the future for doctors. This prediction is basically a guess based upon what has been revealed so far about the ACA.
I did not say what my personal opinion is about the plan. In case you think that all doctors oppose the ACA, that is wrong, and many are pleased that it was passed and will be implemented.
My interest on Blogfinger is to report on what is happening from the perspective of a physician, with a focus on quality care and physician practices.
PG
I have the greatest respect for the service that dedicated, patient centered doctors provide to their patients. That said, I am truly puzzled by why you blame they ACA for the anecdotes you cite — given that the ACA has not been implemented?
The corporatization of health care has been a long time coming, and it is not the remotely the fault of President Obama. Anyone who has fought a health insurance company at a time a family member needed critical care well knows that,
Since the Truman administration, doctors aggressively fought against every effort to reform — and expand — the delivery of health care in this country. Ironically, the AMA fought against Medicare, which is now the key source of reliable income for the medical profession.
Simply put, it is hard to see how it could be a bad thing for doctors — and, more importantly, for our country — that people who now lack access to health care at their times of greatest need absent fear of insolvency are now going to be getting it. And that is what the ACA, at bottom, is (finally) going to accomplish.
Editor’s Note: Thank you to those who commented with very intelligent and informed ideas.
Although I try to focus on issues such as quality care and physician concerns, all the sub-topics under healthcare orbit around financial matters including rising costs, insurance coverage, taxes, effects on businesses, financing of the program etc.
Given the inexorable increase in healthcare costs and the proposed increase in covered individuals, it’s hard to see how the ACA will be lowering costs.
Sure it would be great if we could flip a switch and have the Mayo Clinic model take over, but wonderful plans like Mayo and Kaiser are not necessarily adaptable to the rest of the country. However, elements of those plans will likely become mainstream in the future.
If the new plan can deal effectively with fraud, waste and abuse, a lot of money could be saved and plowed back into the system, but that goal is easier said than done.
The implementation of the ACA will take years, and although the framework for it is already being engaged, how it will look in 2017, five years from now, remains to be seen
15 years ago, I was new to the work force, making entry level pay. I could barely pay my bills, but I paid for my own health insurance because it was no more expensive then my car insurance. Now, I am glad my work pays for my health insurance since it is so expensive.
Why isn’t the dialogue more about why we are paying so much more for health insurance? Wouldn’t it be easier and cheaper to work towards lowering costs so more people can afford health insurance rather then having taxpayers pay the higher costs for people who can’t afford it?
Health insurance and the medical care industry have become increasingly inefficient and it appears we are moving towards more inefficiency and less quality as part of the solution.
The other unintended consequence to this is the change in the way a small business supplies healthcare coverage to its employees. As an employer with less then 25 employees or so, they may be getting healthcare through Aetna or BCBS or some other major company. Its probably a decent plan and the Employer uses it as a way to attract employees and a a way to negotiate when the employees want a raise. It isnt a “cadillac” plan but it also isnt a basement coverage.
Once the ACA goes into effect and everyone is now being taxed as individuals, along with businesses being taxed accordingly, the employer is paying one time as an individual and one time as a business for the government healthcare. Would he continue to pay extra for the private healthcare? Probably not. Logically the employer is going to drop BC/BS as he is already paying the government two time over for health insurance.
So you now have employees that were enjoying decent private coverage now being provided government healthcare. How is that a good thing?
I am not sure why we have to have insurance companies running health insurance anymore at all. They are this middle-man trying to turn a profit. Why can’t they just make the Medicare system cover everyone, and get rid of the middleman? Canada has a much better system. They give everyone basic care for their tax money, and if you want superior care, and don’t want to wait in any lines or get on any lists, you can go buy your own private insurance.
As to the role of the physician, I am not sure they know what is going to happen. Forbes says there is a shortage of general practitioners, but that salaries for them are actually going up and averaging around $200,000 a year. Specialistss are making an average of over $300,000 a year. With a lot more customers entering the system, it is hard to imagine significant suffering on the part of doctors, and their incomes may even go up. Compared with the sick who will now get some basic care, I think it is a fair to expect doctors to make some adjustments with changing times.
While we can debate whether “affordable” health care is a fundamental right or not, the facts are that the ACA, fully implemented, will slow medical innovation, induce a doctor shortage, reduce medical choice, and, for the majority, not lower medical costs. Paul’s story summarizes well the directon we are headed in and its not good.
This article deals with doctors, which is fair enough, but there is another side — the consumer’s side. I know quite a few people, mostly young and middle aged, who were without health coverage because they couldn’t afford it, but who are now looking forward with a sense of great relief to the new system’s insurance exchanges. In fact, they can’t wait. There are tens of millions who weren’t covered before, who will be now. I hope the ACA turns out to be well executed, efficient and fair, as intended.
I would just add that some of the trends Paul describes I’m already seeing in my own doctor, who used to be in private practice but now is part of a group. This group practice seems to be going through all kinds of transitions, some having to do with shared medical records and corporate entanglements that I can’t really understand. I think much of this change was underway before Obamacare, but I can see how Obamacare, with its mandated coverage for many more people, could make the adjustments a bit harder.
There will be some access issues if you go ahead and provide insurance for 40 million additional lives. Your concerns notwithstanding, one of the benefits of Obamacare is that there will be many incentives to improve the productivity of the system, largely by institutionalizing care. Why do organizations like Mayo Clinic and Kaiser, which provide excellent care, have only salaried physicians? It’s a proven model for success.
Yes, there may be less and less private practice of fee-for-service medicine, which has served the medical profession well since Medicare was enacted in 1965. Since then, it has promoted over-utilization of services, variations in practice (studied to death by Wennberg and others for decades), fragmentation of patient care, and yes, greed. As a knowledgeable patient with decades of experience in the industry, I won’t be sad to see it go—and the sooner the better.
When you send a chart out for an expert opinion, the treatment plan changes 80% of the time,and the diagnosis changes 50% of the time. Who needs this? I’d much rather have care based on standards that work consistently, with less variation and a better outcome.
Being honest about it, the ACA will benefit 25% of the population at the expense of the other 75% for whom the quality and availability of care (and choice) will decline. Doctors will get screwed (a process well underway already). This is a microcosm of how socialist programs operate and how America, as a increasingly socialist country, will evolve.
The pursuit of “social justice” will lead to the majority of people having a lower standard of living so that the minority gets more. Without appropriate levels of reward, who will want to become a doctor, or risk their capital on a new business, or sacrifice all their waking hours for 10 years to get ahead? In the end, everyone will be poorer — which is exactly what the majority of Americans have just voted for.