By Hal C. Scherz, MD
Twelve months after the passage of one of the most controversial laws in American history, healthcare is still an unsettled issue. Never before has a president needed to go around the country to defend and sell a bill that he signed into law. America has been subjected to a law that over 1000 groups, representing 2.4 million people has been exempted from because they discovered that they could not afford the increased costs associated with it. This is before the law has even gone into effect. The bitter irony is that many of these groups who have received waivers were the most vocal proponents for this law, including the SEIU. This is cronyism at its worst and just a taste of things to come when the Federal Government, under the watchful eye of the Secretary of HHS decides what treatments doctors may deliver to their patients.
As physicians, we are already beginning to see the profoundly adverse effects of the Accountable Care Act (ACA) on us and our patients.
This year, the Medicare SGR (sustainable growth rate), which required a 23% reduction in physician reimbursement, was postponed 5 times. The final reprieve, resulted in Congress “kicking the can down the road” until January 2012, when the reduction becomes 29%. Meanwhile, the new Medicare fee schedule goes into effect in October, with across the board cuts of approximately 7%. During 2011, CMS (Centers for Medicare and Medicaid) withheld payments to physicians on TWO occasions, for as long as 45 days. This presented tremendous hardships for doctors whose practices are largely made up of patients on Medicare and where these payments represent a large portion of their income.
Many doctors needed to take personal loans to meet payroll. Many doctors did not take home a paycheck even though they had provided services. Some doctors needed to down size, which meant layoffs of employees, and still others needed to close their practices. And thousands of doctors, who have been caring for Medicare patients for over 40 years, simply had enough and either stopped taking new Medicare patients or left the Medicare system entirely. And who could blame them? Any business needs to have some degree of predictability in order to survive, and Medicare has become too unpredictable to base future decisions upon.
The losers are not so much the doctors as are the seniors. They have paid into a system during their working lives, and now many struggle to find a doctor. With $500 billion slated to be cut away from Medicare, the benefits that seniors will receive will diminish as well.
The care that these seniors and others receive will not be as good as the care that patients currently get. One reason is that the ACA makes it easier for non- physicians to deliver healthcare. The new law emphasizes the concept of “medical homes”, which will be the gatekeeper in future healthcare delivery models. Nurse practitioners and physician assistants are elevated to physician status by virtue of this law. It is the attempt on the part of the federal government to convince the public that there is equivalency between all healthcare providers, but sadly that is just not so. It is the beginning of the attempt on the part of the government to condition the public for a lower standard of healthcare. This statement is not meant to be derogatory to this group of professionals, but simply stated, they are not doctors; they are physician extenders. It takes 7-15 years of education and training, long hours and personal sacrifice to become a doctor. A physician cannot simply be created by a legislative edict.
Yet, this is precisely what is happening around the country. Clinical psychologists in California are being giving hospital admitting and prescription writing privileges, optometrists in some states are given eye surgery privileges, including laser surgery privileges in Oklahoma, and nurse anesthetists are designated as equals to board certified anesthesiologists. Pharmacists are lobbying for the ability to change prescriptions written by physicians not to generics, but to entirely different drugs, if they think that it is warranted. And nurse practitioners are now able to do an extra year of training and come out with a doctorate degree in nurse practice, so that they can call themselves “doctor” as they populate primary care clinics and medical homes.
The HITECH Act which was actually in the Stimulus Bill of 2009, was essentially activated by passage of ACA, so that now, all doctors who wish to receive the highest levels of reimbursement for the services that they will have already provided, will need to have a health information system in place that meets federal standards. This is not an entirely bad concept, were it not for the fact that the systems currently available are not yet ready to accomplish the integration of clinical information between doctors, hospitals, pharmacies and other sectors of the healthcare spectrum. We will get there at some point, but to force doctors to spend money now on systems that cannot meet these goals is absurd.
The systems are pricey, and the costs cannot be passed along, so doctors have to assume them all themselves. Consequently, less money will be available to spend on patients whether that means fewer personnel in doctors’ offices to care for them or less sophisticated tools available for the doctors. The systems that doctors are being forced to adopt will soon be surpassed by better systems that will be developed that can do what we expect from them, and then doctors will have to incur the costs to retool their offices once again. The problem is that when the technology is developed, every doctor will want to adopt it and not before, just because it has been decreed. The money that is supposedly available to doctors who implement these systems and who demonstrate “meaningful use” will barely cover the incurred costs, assuming that there is money available to begin with.
The government and insurance companies are looking for alternative healthcare delivery models and the ACA supports one such model- the Accountable Care Organization (ACO). This organization is intended to be a vertically integrated healthcare delivery system consisting of physicians of all specialties working together, by following clinical protocols and best practice models, so that care can be coordinated and waste can be eliminated, while delivering improved care. This medical utopia would work with the hospitals as partners, but what is instead happening around the country is that hospitals are buying up physician practices at a record pace so that they can control as many patients as possible and hence control the medical market in their community.
The physicians in this “super HMO” are employees and they then have to choose between doing what is right for their patients and what their employers instruct them to do. This is already happening in hospitals across the country, but will escalate as more physicians, especially specialists, leave private practice because they fear that their practices will have no value if the hospitals control the flow of patients to them.
Besides encouraging the formation of ASOs, the ACA has other provisions which are aimed directly at doctors, in an attempt to destroy the private practice of medicine; a necessary first step to get to a single payer, government run healthcare system. Working with a willing accomplice, the American Hospital Association (AHA), provisions were put into the ACA that eliminates future physician owned hospitals and surgery centers, imaging centers and laboratories. The exemptions to these ventures occur when they are connected to and are a part of the physicians’ direct practice, but these exemptions are being challenged as well. The AHA is a very powerful lobby and as we have come to see, doctors have no effective lobbying group and are easy targets for every group that wants to push us around.
Finally, the worst part of the ACA lies in the limitless power granted to the Secretary of HHS when it comes to healthcare matters. The Secretary determines what the clinical protocols are which doctors must follow if they wish to see patients who have insurance that is offered through the healthcare exchange. According to the ACA, there will be no insurance offered outside of the exchange. So if you want to see insured patients, you must follow the protocols approved by the HHS Secretary.
If this wasn’t bad enough, the Federal Coordinating Council for Comparative Effectiveness, a 15 person board appointed by the President and with no Congressional oversight, will decide what treatments doctors may offer to patients and which cannot. Simply, this is the beginning of medical rationing, and if the issue of waivers bothers you, then this should really scare you. “trial balloons” have already been sent up in this regard. We have seen it with mammogram recommendations and with limiting Avastin for breast cancer patients. You can be certain that It will escalate as new ways to limit care are explored.
Dr. Scherz is the Founder and President/CEO of Docs 4 Patient Care (www.docs4patientcare.org).