Monday, June 27, 2011

Hey, Doc, do you remember the “good old days”? (circa 2008)

Woody Allen’s “Midnight in Paris” is a modern day parable of people looking back to another time as being better than their own. Some physicians seem to think 2008 was that better time, before Barack Obama was elected president and his health reform initiative became law.

You know, in 2008, physicians weren’t facing huge Medicare cuts. Medical liability awards were capped across the country. Everyone had health insurance. Government regulation was non-existent. Physicians could order any test they wanted without second-guessing by insurance companies. Young medical students were beating down the doors to become primary care physicians, and patients had no problem getting same day appointments with their internist.

You don’t remember it this way? Of course not, because it wasn’t so. But given some of the over-heated rhetoric from some physicians who are critical of the Affordable Care Act, you’d think that everything that is bad about medicine today is a consequence of “ObamaCare”--even though most of the law hasn’t even taken effect!

In 2008, before Obama got elected, before the Affordable Care Act became law, physicians faced double-digit Medicare SGR cuts and skyrocketing med mal premiums. In 2008, 46 million people didn’t have health insurance and there was a projected shortage of over 40,000 primary care physicians. In 2008, the U.S. scored poorly compared to other countries in two measures of access to doctors, having to wait more than 6 weeks to get an appointment and getting same day appointments. In 2008, more than nine out of ten primary care doctors reported an increase in time spent on non-clinical paperwork over the prior three years.

How then can anyone fairly pin these things on the ACA, which wasn’t enacted until March 2010, and won’t become fully effective until 2014?

A fairer yardstick would be whether the ACA makes these things better, worse or makes no difference

By this yardstick, the ACA didn’t solve the medical liability problem nor eliminate the SGR cuts, but neither did previous administrations and Congresses.

By this yardstick, the ACA will invest billions of dollars in dozens of programs to increase the numbers of primary care physicians and improve payments for their services, even though it doesn’t solve a workforce shortage that pre-dates it.

By this yardstick, 34 million people who today are uninsured at least will have health insurance, and with it, improved access and better outcomes, although wait times for appointments initially may go up as a result.

By this yardstick, the ACA didn’t end paperwork the paperwork burden on clinicians, but it will require insurance companies to streamline and simplify authorizations, transactions, and eligibility verification and to spend more money on patient care and less on administration, even as some of its other programs may add to red tape.

Perspective is important. The U.S. health care system had big problems before the ACA and, it will have some big problems after it. The ACA makes some big things much better (getting people covered), makes a stab at improving other things (training more primary care doctors, reducing insurance red tape), may make some things worse (longer appointment waits because more people will be covered), has some things that need to be changed (like getting rid of regulations that could add more red tape), and doesn’t fix some things that need fixing (SGR and medical liability reform). But this doesn’t fit in with the critics’ narrative that everything that is wrong with American health care is the ACA’s fault, including all the things that physicians and patients didn’t like before it.

Unless, of course, you buy into the fantasy that 2008 was the golden age for American medicine, until the ACA came along to destroy it.

Today’s question: Do you think it is fair to pin on the ACA the problems that existed before it?

1 comment :

PCP said...

Bob you can try to put lipstick on this pig anyway you want. It won't glamorize it at all.

The trajectory of the ACA is clear, it is a path of failure. I happen to think that loss of professional autonomy is the worst part of the ACA. However on your same scorecard.

The act will do as follows. It will overburden Medicare, as it does nothing to deal with the demographic tsunami that is reaching ashore. It will then lead to lower below cost reimbursements for our services, leading to worse access issues than currently as physicians find alternative uses for their industry and skills.

Bob, you and I both know that what the ACA does is a token increase in PCP training. We also know that the solution to this poor allocation of physician manpower is a reconstitution of the RUC. What we have in this country is a mal-distribution of doctors geographically as well as in terms of specialties due to price fixing by the RUC.

ACA will teach the lefties that insurance does not equal access. Medicaid recipients already know that and show up in the nations ERs at a higher frequency than those with commercial insurance.
The administrative burden has been so great under ACA(for example the EHR recurring cost mandate) that it will lead to more retirements of older doctors than anytime in the past 20 yrs.
ACA will lead to more astonishing things like yesterdays purchase of a failing hospital by a health insurer. Emergence of hard non accountable monopolies around the country.
The sad part of this all is that the ACA approaches health care reform from the perspective that Physicians are the problem and therefore need to be boxed in further rather than that we have been the victims of over regulations yearning to be free and entrepreneurial and contract with our patients instead of salaried by gov't endorsed monopolies.
Heck the ACA even goes as far as to limit HSAs and ban physician owned hospitals.
What malarky supported by organised medicine.