Healthcare Reform/Private Practitioners

Healthcare Reform: A Private Practitioner’s Perspective

The Decline and Fall of the American Medical Profession

Edward R. Rensimer, MD, FACP

Abridged Version

 

I am a 63 yr-old self-employed medical specialist who has practiced internal medicine (one aspect of primary care) as well as the specialty of infectious diseases since graduating medical school in 1975. My experience includes 40 years caring for patients (over 40,000 cases), both outpatient and hospitalized. I have served in appointed and elected office in the Harris County (Houston) Medical Society and Texas Medical Association. I was elected and served as Chief of Staff in a major Houston hospital with a physician staff approaching 1,000.

I have loved what I do. Yet, I would not have done it in the face of the developing healthcare reform proposals and prospects.

Much of what we read about healthcare reform and our healthcare system comes from the media, politicians, medical business leaders, and “organized” medicine (the American Medical Association, etc.). Missing from that group are the actual doctors who treat patients and understand, like no one else, how the system works, and how it does not.

If ever there were a “silent majority”, practicing physicians are it. Ironically, although we have the most relevant information and attitudes regarding the real-world, practical interests of patients, our input was not requested in trying to reform healthcare. Instead it was the input of Big Business Medicine which shaped the Affordable Care Act/ObamaCare: hospitals (American Hospital Association), drug companies, insurers, medical equipment companies, medical services support providers (labs, imaging, home health companies, nursing homes); the combined medical academy (university teaching hospitals, medical schools, and medical journalism); and, of course, the Federal Government. This is a virtual medical-industrial-governmental complex driving “change”, above and upon practicing physicians and their patients.

CORE PREMISES

1. We will all be patients.
2. Uninsured does not equal untreated.
3. The validity of much modern medical research has been questioned, and so conclusions about “best practices and “quality care”, based on that research, are not always reliable.
4. The prospect of Government in any way getting involved in managing and controlling previously private enterprises, such as insurance, should always be questioned and discouraged.
5. Physicians subject to government requirements under the ObamaCare system or other third party payors or physician employers creates a significant potential conflict between “answering to the employers (government)” and meeting the fiduciary and ethical duty to the patient.
6. You get what you pay for; if you pay bottom-of-the-barrel rates, you can expect matching performance from your physicians and other providers.
7. Deals that are too good to be true are.
8. A self-employed physician directly and autonomously working for a patient is the best possible, unconflicted means of healthcare delivery. It also provides the extra incentive of a free-market where the patient can choose and pay for the best service and expertise.
9. Rationing, under ObamaCare/ACA, is inevitable.
10. ObamaCare will change the relationships between the U.S. citizen and the federal government in a fundamental way involving the most highly personal issues of the citizen, heretofore not seen. It is an entire restructuring of the citizen-state paradigm.
11. Unbearable costs of running independent (small scale) medical practices with payment reductions by Medicare and private insurers have created business consolidation local monopolies by hospitals over physicians and patients.

THE PROBLEMS

1. The average share of medical practice overhead costs increased from 36% in 1970 to 60 – 70% now.
• Average physician income from 1975 – 1983 rose 8.7% per year; since, it has declined when adjusted for inflation.
• Support staff have grown from 4.5 persons for 2 physicians to 4.5 per physician, doubling support staff, mainly due to administrative and regulatory burdens, not increased service to patients.
2. Students typically graduate with over $200,000 debt from medical school alone.
3. Payment rates for services by Medicare have been generally frozen for years and those from private insurers also have been also frozen or declining; many of the major private payors reimburse at or up to 20% below Medicare rates.
4. Projected Physician Shortage and Current Physician Problems,
   1. In 2010, the Association of American Medical Colleges projected a shortage of 130,600 physicians by 2025 (half of those in primary care).
   2. With ObamaCare there will be a 36% rise in Americans eligible for Medicare.
   3. Long work hours, decreased time with patients, onerous regulations, problematic re-imbursements, Governmental fraud and abuse prosecution threats, inability to survive as a private practice business model, little personal time (=Burn Out). While physicians see it as a calling, the negatives start to outweigh the positives by far, especially as professional autonomy is surrendered to Big Business and Big Government.

COMMENTARY: Younger doctors have gotten the message. Many graduates are aiming at specialties that give services not covered by insurance (cash-pay) and/or that have fixed, limited work hours.

The Affordable (or Unaffordable) Care Act (ACA) a/k/a ObamaCare

Some of the significant consequences of ObamaCare:

1. ObamaCare applies to everyone, EXCEPT those who are granted exemptions, Why did the politicians who “passed” the law choose to exempt themselves from ObamaCare?
2. Independent Payment Advisory Board (IPB)- the care rationing authority,
   1. IPB is given unprecedented authority to cut Medicare reimbursement rates to care providers, strangling access to care.
3. Of the $716 billion ObamaCare siphons off Medicare, $418 billion (more than half) are a reduction in payments to doctors and hospitals (“providers”, in ACA language).
4. ObamaCare Features
1. Doctors and hospitals are paid according to Government discretion.
2. Your doctors’ recommended treatments may not be approved.
3. Waivers (to be exempted from ObamaCare) for special interest groups are granted at the discretion of the Secretary for Health and Human Services (as overseen by the President).

What It All Means,

1. Physicians, overwhelmed with onerous work, regulatory, and business conditions, and uncertainty over the future of healthcare under ObamaCare, are looking to cutback and drop-out, many going to employed positions.
2. “Evidence-based” practice has become the buzzword for healthcare reform. But, because the data are often suspect, the conclusions for what constitutes “best practices” may be founded on faulty information. If the data are faulty, the conclusions fall like a house of cards.
   

   Per John Ioannidis, MD, arguably the world expert in biostatical analysis of medical information validity, as profiled in The Atlantic, November, 2010, in “Lies, Damned Lies, and Medical Science”, the studies/information routinely published in leading medical journals are frequently flawed in premise, validity, and conclusions. It is so whether for research and clinical purposes.  Apparently, the pressure to publish the most dramatic findings (“breakthroughs”) by those whose careers depend on it, creates an inescapable bias and corruption of process. So, as much as 80% of published information may be misinterpreted/skewed, if not flat-out wrong.

   About 62% of treatments are not evidence-based.

   Dr. Brian Berman found in his analysis of completed Cochrane reviews of conventional medical practices that 38 percent of treatments were positive and 62 percent were negative or showed “no evidence of effect.”

   Note, I am not contending with efforts at evidence-based medicine, quality measures, comparative effectiveness research, and pay-for-performance as attempts to establish validity and value in medical practice. It is a place to start. The problem is who gets to set this up and analyze it, and subsequently direct the healthcare dollars by it? More importantly, what are their agendas? Are they aligned with practicing physicians and the patients, or political leadership and Big Business Medicine?

3. Electronic Medical Record (EMR)/Computerized Records
   1. A New York Times article of 10/9/12 stated, “…electronic records… the challenges have proved daunting, with a potential for mix-ups and confusion that can be frustrating, costly, and even dangerous”. Physicians have claimed they could only see half as many patients when forced to use EMRs. Nurses had the same complaint.
   2. EMRs are one of the keystones in ObamaCare’s and Medicare’s drive toward decreasing waste and improving efficiency. EMRs are not user friendly at this point for the type of work that doctors do. They are designed by IT and electronics engineers, not physicians, so they do not work the way physicians work and think.
   3. EMRs, as currently configured, make doctors and nurses into unreimbursed data entry clerks. Thus their limited time is re-directed away from patient care and to the keyboard.

Results

1. We have moved fully into ObamaCare implementation with pay-for-performance, EMRs, electronic prescribing, accountable care organizations (ACOs), “medical homes”, preventive services, evidence-based medicine, comparative effectiveness research, and pay-for-performance as central tenets to achieve the ObamaCare’s intended outcome of universal healthcare coverage  and access that is financially covered. Every one of these premises is questionable and unproven. Yet, our current medical care system is undergoing rapid, probably irreversible in any reasonable time, overhaul based on these principles. In other words, going the wrong way, on a one-way road, under wrong assumptions, at full speed.
2. ObamaCare Changes,
1. Payments to doctors will be influenced by cost of treatments and their results; which will influence what cases doctors take on and what they decide to do with them.
2. Sick/complex patients will negatively impact a doctor’s ratings.
3. Pay-for-performance,
1. Encourages cherry-picking patients (less complex, easier path to good outcomes, at lower cost); the easiest path to good “grades”, and so pay, will be the one more traveled.
4. Many doctors are no longer accepting Medicare; many more are considering dropping out of the program.
5. Special interest groups WAIVED from ObamaCare,
1. Teamster Local No’s 175 & 505
2. Laborers National
3. MO-Kan Teamsters
4. Theatrical Stage Employees
5. Midwest Teamsters
6. Florida Laborers
7. United Service Employees Union
8. United Federation of Teachers
9. Many others (easily found on Internet)

Notably, those pushing ObamaCare, the U.S. Congress, the President, and the Vice President will not be subject to ObamaCare. How are these entities exempted them a “general tax” on everyone else? Is that what the president means when he refers to paying your “fair-share” (when wanting to increase taxes on the highest 1-2%)? This alone should stop ObamaCare as a political property redistribution taxation tool, rather than “reform”.

The Future

1. Physicians
   1. Doctors will exit Medicare, meaning less doctors, which translates into less access to care and to needed expertise.
   2. Nurse Practitioners and Physician Assistants will be increasingly used as the providers of medical care. To remain solvent, practices will go to lower cost staff to see the patients. This will be further propelled by the 62,900 doctor shortage by 2015, expected to double by 2025. Expect the Government to try fast-track training of doctors in the U.S., as well as importing foreign medical graduates (not the high quality of those who currently make it into U.S. practice). Can you fast-track comparably excellent physicians into practice? If so, why has this not been done before? Failures to diagnose and treat will be commonplace (a form of rationing; if you don’t diagnose it, you don’t treat it – a dead patient is cheaper than a sick live one).
      

      But, the trend to increasing reliance on midlevels undoubtedly will create   standard of care problems.

2. Hospitals, seeing a shift away from payment for inpatient, high-expense services are avidly trying to buy medical practices and to employ doctors, ultimately “owning” the patient base.
3. Increasing Government-based insurance, until there is finally national health insurance monopoly. By January, 2012, the massive new regulatory load under ObamaCare prompted private insurance carriers to reduce or eliminate coverage because the writing is on the wall, according to the Galen Institute.
4. Increasing influence, intrusion and control by Medicare (and, ultimately, a National Health Service) of your treatment options and what doctors will be available to you. Once the government under-prices private insurers, small and big businesses will need to go to the government option (the ACA will drive private insurer prices through the roof). Then, the government will become the “provider” of health services.

DISCUSSION

Total up all I have said, and it is alarming where all this leads. Premises which are unproven. Onerous enforcement on an entirely unlevel playing field for individual doctors and patients. Medical- industrial complex power players negotiating with Washington to divide up control and power. Massive tax increases as a redistribution of wealth to be brokered by career politician aristocrats, exempted and protected, like a politburo, from the very “change” they sell in populist rhetoric. And, at the very center of this are the most disempowered of all- physicians and patients.

But, be clear, without any hyperbolic intent, this is Big Brother and the march to socialism. It will be incremental. Unacceptable change almost always is.

The ACA will lead to a national healthcare system in due time. Access to care may be ok for wellness problems, but it is likely that expert medical specialists will be in short supply as doctors are rewarded for keeping costs down (less diagnostic tests, less costly treatment). Taking care of those who need least care (primary care) will be desirable as pay for service is marginal and doctors are rated for the costs they run up. This will lead to “cherry-picking” patients. An article in The New England Journal of Medicine, Oct 11, 2012, stated , “ There are lingering concerns that pay- for-performance may lead providers to avoid the most seriously ill patients…”

Private practice is, over time, becoming a thing of the past. The new medical world will likely be almost always seeing a non-physician surrogate after long waits for appointments, and long waits at appointments. It will be your physician being more concerned about accountability to his employer than to you. A study published in The Journal of the American Medical Association, 12/4/12, showed that over 75% of U.S. med students continue to choose higher-paying subspecialties over primary care. The main goal of health reform of creating greater access “to your doctor” is implausible with a projected shortage of 52,000 family practice/general internal medicine physicians in 12 years. These data were from a survey of 16,781 third-year med students. The intention to do primary care is down 50% from the early 1990’s. The touted primary care “medical home concept” will become a torrid patient production line with ramped up responsibility for the primary care doc “supervising” midlevel providers, filling out piles of paperwork, appealing to business management boards and government overseers, all at marginal wages. Oh, and you get regular “report cards” from non-physicians. Anyone want to sign-up for primary care? Medicine is already too hard and demanding a profession to expect the best and brightest to work within a bureaucracy rigidly controlled by non-physicians and at unimpressive pay. Few will give up their youth to train for this, unless they are not exceptional students.

Medicine may become corporatized and federalized, but, like politics, medical practice is local – an intimate, interpersonal experience. Exceptional people will not be drawn to the “new medicine”. They will go elsewhere and the profession will be mediocritized by those without the capacity to understand what they are ruining. This mediocratization will probably be irreversible, as the academic institutions likewise devolve to match mediocre students.

Politics and religion are best kept at a distance from the physician-patient relationship. But, when societal change of such magnitude and danger is contemplated that is in their backyard, the profession and its individual practitioners have an obligation to take a public position. Physicians must explain to the public that their profession is dying, and what that means to them and their loved ones.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000… That is what is happening to the medical profession in your home town, just down the street. Ask your physicians. Corporate medicine is as big a problem as ObamaCare. So, even the AMA is on board that a doctor may not be able to serve two masters, and the patient will probably come out on the short-end. Corporate medicine and the feds are squeezing the life out of the profession.

Carried to the ultimate, big players, like hospitals, will be the “provider” and the patients branded as theirs (by whatever payor plans the hospitals capture and whichever doctors they have bought). That is what will determine patient care. On 5/12/11, The New England Journal of Medicine stated, “employment choices that physicians make today may not be able to be undone”. In other words, a decision made under business pressure may very well preclude a return to private practice after physicians have turned over their patients to the hospital and agreed to align their practice actions exclusively with the physician model and culture assembled by the hospital (walking away from colleagues they previously preferred). The physician is locked-in to the hospital employer, and locked out of his community and access to patients on a free-market basis. ObamaCare is a scheme, built largely on fantastic conjecture and speculation, that creates a playing field on which large corporations and the Government will contend with each other, with individual practitioners and patients the unheard victims. One day we will all awaken and say, “What happened?” “How did we let it get this way?” It will be too late. It is already underway. Corporate medicine and ObamaCare will radically intrude on and corrupt the physician-patient relationship.

A brief word on rationing. I am unclear on whether we have enough resources to sustain care at the level to which the American people have become accustomed. It may not be possible, especially as medical science and technology are exponentially productive with expensive innovations. Politicians are not being forthright about this.

However, rationing will not occur through “death panels”. Politicians know the American electorate would never tolerate it (they cannot even stand the possibility of a lower Medicare entitlement, so it is not discussed, or a political career is over). No, the elements for rationing will be rolled into place, partly by corporate medicine (mainly hospitals) and the Government, in a subtlely sophisticated way. The elements have been in place and coalescing preceding ObamaCare and the ACA builds on that,

1. Independent Payment Advisory Board (IPB – see above)
2. Mediocratization of the Profession:
   1. Emphasis in training and practice on “wellness”
   1. We will all become ill, despite this idea. When we are, we need specialists. When PCPs or their families become seriously ill, they go to specialists.
   2. Decline and Marginalization of Specialists
   1. The 1/1/13 edition of the Association of American Physicians and Surgeons News stated, “Patients having major surgery are four times more likely to die in a British than in an American hospital; seriously ill patients are seven times more likely to die, owing largely to a shortage of specialists and lack of intensive care beds… Spot checks by NHS regulators found that half of 100 hospitals were failing basic standards on treating the elderly with dignity and seeing that they were properly fed.” This is what you got when a non-medical (government) overseer kills the expertise of a profession by underfunding and removal of authority and accountability. See our future.
   3. Patients will be kept at the primary care level as long as possible, mostly seen by physician surrogates – highly trained nurses. Inadequate, below standard of care performance sooner or later will engender anger and desperation in the patient/family….at which point, they are “dumped” on the specialists.

      Note: Ready access to unparalleled medical and surgical specialty expertise for critical and complex illness is the signature of our healthcare system for which we are known worldwide. This is the “illness” side of the medical system dichotomy. ObamaCare, over time, will severely diminish this. Patients will recall this aspect of the “gatekeeper” restrictive and obstructive philosophy of care from the HMOs of the 1980’s-90’s. Once established, the mediocratization of the profession and the associated deteriorated medical training academy will be irreversible.

   4. Tort Reform
   1. Doctors and hospitals will be increasingly protected from litigation and substantial financial jeopardy for less than standard care, which will be permissive to a dumbed down, mediocre or worse level of care.
   2. Stifled Dissent

      Already in place at most hospitals are mechanisms in place to rigidly control behavior of staff and physicians. Political correctness is the standard. “Disruptive behavior” is handled with suspension of professional privileges, “anger management” courses, “cultural sensitivity” courses, expulsion from the medical staff, and even professional ostracism by those who do not want their neck on the block next. The individual physician does not have a chance for due process if judged a dissenter or not a team-player. And, this will only intensify when physicians are mostly employed. They will have no leverage. Whether the doctor is personally disruptive or is reasonably reacting to a “disrupted” patient care process or unsafe hospital environment, on his patient’s behalf, is beside the point. Once you whistle-blow or dissent, you have nowhere to go in your own community as the corporation leans on your colleagues to walk away from you. When you are an employee, the corporation “owns” the patient base and medicine is not a very mobile profession. Your business is built on longstanding relationships.

   5. ObamaCare/Medicare proposes insurance model reform, electronic medical records, preventive medicine, pay-for-performance, accountable care organizations, comparative effectiveness research, and the “medical home” concept as the ways to afford paying for universal insurance without any diminution in quality of or access to care. An excellent article in the Annals of Internal Medicine, 4/7/09, reviewed all these ideas and showed that they or very similar schemes have been tried and failed in other foreign, industrialized nation healthcare systems. It goes on to say, “Savings would, of course, also depend on the political willingness to reduce payments to medical providers.” (hospitals, doctors, other medical professionals and businesses; those we rely upon to care for us and to do the work). Remember, you get what you pay for.

The article’s conclusion is that you can “streamline” insurance industry inefficiency and decrease waste, but to decrease cost of care, you must give less care (ration it) and you must pay the care-providers less. And those who accept such pay will very well likely supervise rationing of your care, as directed by the central bureaucracy. It all works.

The dilemma then is the high expectations of the American public for themselves and their loved ones (the best care from the most highly expert, effective providers), yet an intention to create a highly regulated and controlled environment that will not well tolerate highly individual professional style and creativity, discourage autonomous practice, and pay as low as possible – not exactly the formula for attracting and retaining talent. It is an impasse. The American public can’t have it both ways, and the politicians won’t say that. However, the leaders directing “change” will have their own private system of care with its select, expert physicians that the public expects for itself.

As time goes by,

1. The physician – patient relationship will be radically deconstructed, with patients being “handed- off” as they make their way from office, to hospital, to rehabilitation facility, to nursing home, to hospice. It will be system-centric, not patient-centric (personal) model.
2. Unusual and complex diagnoses and problems will be recognized and managed or resolved less and less. If the situation is not simple and ordinary, prolonged suffering and death will be the commonplace outcome.

I will close by stating the obvious… the government is not us. Nor are hospitals. They are special interest groups which will protect their interests. Physicians and patients must find a way to do the same, on as level a playing field as possible, as soon as possible And, remember, we will all, in time, be patients.

 

 

 

Edward R. Rensimer, MD