Stanley Feld M.D.,FACP,MACE
Over the past 30 years practicing physicians have seen their revenue fall. As Medicare deficits have increased the government has lower physicians reimbursement.
Who is responsible for the deficit increase if physician reimbursement has decreased?
Private Insurance premiums have increased because of advances in technology and increases in specialization leading to increases in testing and physician visits.
Private insurance reimbursement to physicians has decreased in an attempt to keep premiums as low as possible for the private employers who need to be able to afford insurance for their workers.
Physicians have tried to compensate for this decreased reimbursement by seeing more patients. Despite seeing more patients physicians’ incomes have fallen.
Physicians’ overhead has increased. The need for more full time employees has increased. As government regulations have increased many practices have had to hire full time employees to do coding for care and paperwork. Physicians have tried to buy fully functional computer systems but they have failed. Computer systems are expensive and not completely functional.
“Physicians have seen their incomes fall, their clout with insurers shrink, and their practices weighed down by a plethora of new requirements. “
What is the value of a physician’s service? What is the value of secondary stakeholders in the healthcare system?
These are hard questions to quantify. The goal of healthcare policy makers is to reduce the national healthcare costs.
The healthcare system is fragmented, complex and unbalanced. Many physicians feel their skills have been devalued by payers, hospital systems, policy makers. These groups have become more powerful than the representatives of physicians’ organizations.
Healthcare has become a gigantic industry costing our society 2.9 trillion dollars a year.
Healthcare has, unfortunately, become all about money with the third party payers making the rules. Effective medical care has been stifled.
Physicians barriers’ to effective medical care are,
1. Lack Of Malpractice Reform
Government has estimate the value of malpractice reform incorrectly. It thinks malpractice costs the healthcare system 3 billion dollars a year.
Several good studies estimates the lack of malpractice reform costs somewhere between $200 billion to $750 billion dollars a year without including the cost of the wear and tear on physicians and patients.
2. Problems Trying to Increase Reimbursement
3. Lack of Negotiating Clout
4. Being Turned Into Captives of the Insurance Industry and the Government
Physicians do not have the ability to modify charges on the bases of costs. Medicare and Medicaid won't allow physicians to negotiate reimbursement rates. Physicians must take the reimbursement fees or refuse to participate in Medicare or Medicaid. More and more physicians are leaving the Medicare/Medicaid system.
Private insurers have forced physicians to sign contracts limiting charges. Individual physicians and physician groups have little negotiating power or ability to have loss leaders as do hospital systems with multiple hospitals in a regional area.
Physician organizations have not negotiated for physicians. Some organizations have teaching courses that teach physicians to get around the loopholes in the healthcare system.
Physicians have no incentive to add innovative programs. These programs can increase their overhead without being reimbursement.
All of this is to the disadvantage of patients and patient care as insurance premiums rise and access to care falls.
Intuitively physicians know that the medical care contract is between physicians and patients. Third party interference has stood in the way of this interaction. It has disrupted and/or destroyed patient/physician relationships.
More and more physicians are dropping out of Medicare, Medicaid and private insurance because they cannot deal with the third party interference with the practice of medicine financially or emotionally.
Rob Lamberts, MD, an internist in Martinez, Georgia said "Doctors have been turned into tools of the insurance industry," "You always work for whoever pays you. When you work for an insurer, you are constantly under pressure to do a lot of things that don't improve the care of the patient."
Dr. Lamberts became a concierge medicine doctor.
Concierge medical practices need fewer full time equivalents, do less paperwork, deal with less regulations, have more time to practice medicine and more time to spend with their patients.
5.Being Pressured to Sell Healthcare as a Commodity
6. Being Force Into Abandoning Clinical Judgment
There are many physicians complaining about the commoditization of healthcare. They are complaining about the constant need for authorization of care demanded by the government and the healthcare insurance industry.
Physicians complain that insurers and other corporate interests have too much control of healthcare. They are dictating what clinical decisions physicians can make. Physicians are becoming accountable not to their patients but to what other interests decide. The system is forcing doctors to give up their medical judgment in favor of clinical practice guidelines.
The clinical guidelines are used to determine prior authorizations. These guidelines are used to determine reimbursement in many pay4performance contracts and shift the risk burden onto physicians.
Several studieshave questioned the validity of guidelines. Close to half the physicians in the 2012 Medscape survey said quality measures and guidelines will have a negative impact on care.
“Mark Shelley, MD, a family physician from Port Allegany, Pennsylvania, decried what he calls the "commoditization" of healthcare. "The art of medicine has been turned into the business of medicine". "Rather than trying to make patients functional and happy, the physician gets caught up in financial issues, such as whether Medicare will pay for a wheelchair."
Dr. Shelley said. "I know doctors who earn a lot of money and are absolutely miserable."
7. Being Captives Under Hospitals' Thumb
8. Being Shunted Aside by Policymakers
9. Being Shunted Aside by Entrepreneurial Management Companies
Many physicians believe that by being employed by hospitals they are at risk of being co-opted by the hospital's vested interests. In many cases this has been proven to be true.
Many employed physicians have passively aggressively undermined the hospital and its vested interests. Rather than making money from physicians intellectual property hospital systems have claimed that they have lost money.
Hospital employment has been attractive to young physicians just completing residency training. They do not have to make an investment in a medical practice and fear the uncertainty of the future of medical practice.
These physicians’ goals are to have regular and predictable office hours in an outpatient practice setting with adequate coffee and lunch breaks. They do not follow their patients in the hospitals. They have no connection to patients, their anxiety or fears. Patients are interchangeable and seen by the next available physician as in the VA system. A physician patient relationship does not develop.
This is bad for patients.
Another problem is many physicians believe that policy makers have not been listening to the physicians’ perspective about the problems in the healthcare system. Policy makers are trying to solve the problems of our dysfunctional healthcare system from their perspective and not from the physicians or consumers’ perspective.
“Obamacare is often cited as an example of when policymakers turned a deaf ear to physicians' interests. As many physicians see it, the law lacks substantive tort reform, failed to repeal the sustainable growth rate, and doesn't improve healthcare.
Obamacare ignores patients’ responsibility in keeping themselves healthy and staying healthy after being treated. It assumes physicians are responsible for maintaining patients’ health.
Ignoring this point alone will cause Obamacare to fail. There are many other issues involved in Obamacare’s ultimate demise at a great cost to our country and our healthcare system.
America healthcare system is in trouble. Obamacare is causing more trouble for America’s healthcare system.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.
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