By Paul Goldfinger, MD, FACC
This question has so many elements that it could be the title of a book with a dozen volumes. I have personally tried to focus here on questions about how doctors will function under Obamacare and how quality care will be affected in the future. Two issues which I have highlighted have to do with the doctor shortage and the failure of primary care under our present system. I have complained about the continued lack of details regarding how medicine will be practiced in the new system. Many details haven’t even been written yet, but it is clear that there will be major changes that will be defined by thousands of new government regulations that will supersede the traditional roll of the physician.
In the last ten years, a growing number of doctors have given up their private practices to become employees of large hospital systems or else they have folded their practices into huge physician groups. One concept that is evolving to deal with the doctor shortage is the model that envisions a team approach to patient care.
This will invariably allow providers other than doctors to provide primary care. These providers (nurses, physician assistants, nurse practitioners, and pharmacists) will function by following guidelines. Primary care clinics will be set up in thousands of pharmacies, and non-physician providers will be able to have their own offices or urgi-centers and write prescriptions. Doctors will lose control as they become cogs in the wheel, and the doctor-patient relationship will cease to be important.
It will be like the call centers you get when you try to get technical help for your computers. The person who answers the phones has limited knowledge and can only answer an array of set questions. After that you get referred to a specialist. I have heard a physician assistant in a nearby hospital ER say that he can do everything a doctor can. Perhaps the mechanics may seem the same, but the quality is not. I have witnessed potentially serious errors by non-physicians trying to be doctors in local ER’s. Obamacare should be very careful about who gets the keys to the car. It will be a malpractice minefield. We will need many lawyers to protect the public.
The situation is complicated by new ways to practice medicine that are beginning to evolve including genotyping of patients and medical care based on genetic testing. The focus will be on the individual, and care will often be given electronically, for example by using smart phones, wireless technology to monitor patients at home, and emails to communicate with patients. I think these advances will be good for healthcare.
For example, new sensor technology will allow continuous monitoring of blood sugars in diabetics with the data flowing back wirelessly to the provider. Office and ER visits will be less necessary. I recently purchased a device for my iPhone which will record an ECG just by having the patient put two fingers on my phone. This $200.00 device could be given to a patient who, instead of going to an ER when he has palpitations, can record an ECG and transmit it via his phone to a technician on call who will send it to the doctor. Maybe some doctor in Bangladesh will check it for you, but this is exciting.
There are many elements to worry about. I believe there will be a chaotic situation after 2014 until all the issues settle out over time. Meanwhile it will be a worrisome period for patients. Electronic medical record technology is far from being a success, and it can sometimes actually cause problems for patients. These systems are nowhere near being universally integrated.
The pharmaceutical industry is failing to come up with new ideas (except in the area of bimolecular solutions in cancer and cardiac care where drugs can be chosen based on genetic testing.) Medical research sometimes gets the wrong answers and studies may provide conflicting solutions. Sometimes FDA approved drugs turn out to be dangerous. Much of what doctors do don’t work and are not based on science. Medical errors in and out of the hospital continue to cause many deaths.
How will all this shake out? People need to pay attention, get educated, ask questions, communicate on social networks, and try to get the best care they can as they bounce around among the options.
Thanks Jesse. You may have noticed that I avoid discussions of healthcare insurance and financing. That’s because I have no expertise in those areas. But that article in Time magazine contains nothing new. Despite promises to cut healthcare costs, they keep rising. Although I am not enthused about government run healthcare, it seems to be the only way to do something about out of control profits, unnecessary care, fraud and abuse. The cost of essential care for expensive diseases like cancer is unbelievable unless you have Medicare or Medicaid and, even if you have insurance, you may have to pay huge out of pocket charges.
As a med student, it bothered me that sick people sometimes had to go broke in order to pay for their care, and that was many years ago. In our practice, we never billed anybody who couldn’t afford to pay. If they had insurance, we accepted whatever the insurance paid, but that’s true today for most providers who treat Medicare patients. However, our practice was in an area where most patients had good insurance. If we had to run a practice in a community where patients were too poor to have coverage, we couldn’t have stayed afloat.
And, as the Time article points out, much of those excessive charges occur in hospitals. The new system needs to find a way to provide affordable care for everyone. Will that actually happen??
Paul – Thank you for a most interesting, and in many ways, disturbing article on the future of medical care in America. Perhaps at some point, you might want to talk about the escalating costs that come from hospitals and hospital supply houses, as outlined most recently in Steven Brill’s hard hitting article in Time Magazine, “Why Medical Bills are Killing Us.”(Feb. 20, 2013). I am sure that you’ve seen this piece and I would certainly recommend to other Blogfinger readers. It is quite an eye-opener.
Jesse M. Vazquez