A Taste of Obamacare

For all you people that are celebrating this bill, let me give you just a little of what we can expect now:

1. Acute and severe shortage of doctors--especially primary care doctors.

Why: Because this bill does nothing to change the primary problem of incredible waste and inefficiency in the current system which is an overreliance on high cost/high tech care driven by too many specialists, demanding consumers, and medical liability. We already have a critical shortage of primary care doctors in this country and this bill will only make it worse as older doctors retire out of frustration and less and less people enter the specialties of primary care.

2. Number one will be exacerbated by an influx of 30-40 million more people into the system which will increase the volume of people that a diminishing number of primary care doctors will see which will result in shorter visits, longer waits in the office and to get in, and a greater potential for medical errors and mistreatment as the doctor has less time per visit.

3. In a measure to control costs, medical care will move from the time honored system of the patient-physician relationship with the physician using his or her training as well as experience to treat disease to a "best practices" system where treatment guidelines and protocols are based on statistical data and analysis, including cost-benefit analyses and developed by doctors that don't know you. What this means is that instead of treating the individual--we will be treating the patient within the context of populations. It might not sound different, but I can assure you there is a huge difference--let me try to explain:

Today, if you suffer from coronary artery disease or blocked arteries in the heart, you can be treated with medication and/or more invasively with stents or operation. However, statistics show that patients treated with stents and operations (which are very costly) do no better--as a group--than those treated with just medication and lifestyle changes (which is not so costly). The key phrase here, is AS A GROUP, there is no doubt that within that group of people that have more costly treatments, there are some individuals who do much better with respect to mortality and quality of life than those treated with the less costly methods.

So the end result will be that if you are lucky enough to fall within the arbitrary confidence levels set up by the committee that makes the treatment guidelines, then you're treated, if you fall out of the curve---too bad.

4. Since doctors will no longer have much discretion in how you are treated, they will find the challenge of being a mere technician reading a cook book unrewarding and unbecoming the years of training and sacrifice they have endured and will leave the profession or not enter it, further exacerbating number 1 above.

5. As a result of number 1 and 4, you will all be seeing more and more mid-level providers like physician assistants (PAs) and nurse practitioners (NPs) who do not have near the level of training or experience to recognize and treat obscure and rare diseases or complex and complicated cases.

6. The overall quality of specialists will fall and more people with serious or complicated medical problems will not be treated at all.

Why: The current bill aims to reward and punish hospitals and providers based on certain quality benchmarks, like mortality or rates of complications, or infections, and etc. Now on the surface this certainly sounds wonderful--but, if you look a little deeper, what will happen is that a phenomenon that goes on every day in this country called "cherry picking" will become the standard of care.

Let me explain: Cherry picking means that doctors and hospitals will pick and choose only those patients that are going to give them good results....that means that they will be treating patients that are deemed low-risk and that would probably do fine--or even better---without treatment!

Meanwhile, smaller community hospitals and inner city hospitals and doctors that do not have the luxury of picking and choosing only the good risk patients, will have worse scoring on their benchmarks which will mean less money for them (because remember, the "good doctors and hospital" got the money) to invest in research and technology. On the other hand, the "good hospitals" will invest their money on high tech gadgets and technology to treat patients that don't need it (remember, they are low risk anyway) and which will add significantly to the cost of care and which is the major cost driver for out-of-control costs (see number 2 above).

An analogy would be like rewarding a military unit that doesn't fight (therefore has low mortality) with high tech weaponry and protective gear, while punishing the units that have higher mortality (because they are in the trenches fighting)! Which unit do you think would have the higher quality?

7. Of course, there is not a single democrat that will admit it, but someone has to say it. That is, like it or not--there will be rationing!

Why: Look at 1, 2, and 3 above. regardless of what the CBO says or Obama says, healthcare costs will continue to rise exponentially as we rely more and more on costly high tech care (which is again, the biggest cost driver) and since 30 to 40 more million people will be added to a decreasing pool of doctors to take care of them and we obviously will not have unlimited money to pay for that care--that means rationing and very long waiting lists! If you're over 70 and have renal failure--too bad, no dialysis for you. If you're 60 and need a knee replacement--you'll have to wait until all the 50 years olds (and sports celebrities) get theirs because they are more "valuable" to society than you. Need a liver transplant--you better be Madonna or Mickey Mantle. Need a heart bypass--better get in line. Are you 70, 80, or 90 and have a broken hip---too bad, you're not going to get one! You will be given comfort measures and will most likely die of a pulmonary embolus or pneumonia.

8. Insurance premiums will continue to rise and in an attempt to offset that by the government, subsidies will be given which we all know means higher taxes.

Why: Again, this bill does nothing to address the two fundamental problems with American Healthcare: Out-of-control costs spent on high cost/high tech(and even some low cost care such as antibiotics) care and technology--that is often not needed and a third party system to pay for that care.

A third party system does nothing to put the responsibility of (the cost) of health care where it belongs—which is with the patient! As long as there is the perception that someone else is paying for any commodity--then we all by human nature are going to want and expect the best there is and with all the bells and whistles--whether we need it or not! Health insurance should be used only for unpredictable calamities--not routine health care! If we all had to pay for our screening mammograms and colonoscopies, and regular doctors visits, maybe we would shop around and educate ourselves as to whether we really need it and where we could get the best deal! Secondly, as I already mentioned, since the cost will continue to rise and the insurance companies will continue to pay, where do you think the money will come from to pay for it? The tooth fairy?

That is just a short list of what we can look forward to in the next few years--and that's just in health care!

Good luck!

John Vigil, MD (1988), MBA (2011)
Fellow, American College of Physician Executives

Real Reform Must Come From Within The Profession

Real reform is never going to come from Washington. It has to come from us.
When Obama talks about "keeping what works and making it better and getting rid of what doesn't work", he is really talking about remodeling a house with a fundamentally flawed foundation and doing nothing about fixing the unstable foundation.

That unstable foundation is the third party payer system--as long as we have a system in which a third party is paying for an individual's needs regardless of the commodity and regardless if it is government or privately sponsored, there will always be excesses in terms of waste, greed, and inefficiency at all levels of the system, including the payer, the provider of the service or product, and the consumer. As long as there is the perception that someone else is paying for “it”, human nature dictates that we all will want the best while the payer will do everything possible to provide us with something less.

We as physicians need to recognize that we are speaking about fixing a broken system that we are part of and that we are partly responsible for.

No one may want to hear this--especially the specialists but the fact of the matter is that over 90% of all medical care --which does not require high tech or the "latest and the greatest"--in this country can be delivered inexpensively and efficiently in private offices by primary care physicians. However, we are top heavy in this country with specialists and not enough primary care physicians. And, the majority of the primary care physicians are employed--and controlled--by the very system that we all deplore. On top of that, they prefer to work 9-5 and no weekends, take no call, have no admissions, do no hospital work and make as much money as an ophthalmologist doing 50 Lasik procedures a day!

I am in no way saying that primary care physicians don’t work hard or don’t deserve to make a lot of money, I am simply saying that before managed care and before doctors went to work for them, they worked a lot harder and for relatively less money than today. I do however, think that Lasik or LK is ridiculously overpriced!

When I worked in ERs after I retired from surgery, about 70-80% of what I saw did not need to be seen in the ER, especially after hours and on weekends--and, contrary to popular belief, they were not all indigents or uninsured with no place to go--many of them were insured with no other place to go. They had tried to call their doctor and were told to go to the ER or nearest urgent care! Most ambulatory care or urgent care centers are closed by 10pm and so, if the patients are sick—insurance or no insurance—they either wait it out and suffer at home—or they go to the ER and wait it out and suffer there!

So how do we affect reform? We do it by doing what we learned and what we did best in training. We all succeeded because we were trained and were able to work hard and thrive under adverse conditions. We all were able to use intelligence, experience, and ingenuity to get us through difficult situations—especially difficult patient management situations. We relied on each other—both within and outside our specialties—to accomplish a common goal. Of course we still do these things today; however, self-interest has changed how we do these things!

Reform has to begin with us. Plain and simple. We must retake what is rightfully ours—what we worked so hard and sacrificed much of our lives to attain—that is the responsibility of delivering medical care to society. We have abdicated that role which we had for over 2000 years to “big business” and we are dangerously close to having any remnant of that responsibility taken from us by the government.

We don’t need the government crafting and shoving down our throats ridiculous bills that no one can read and much less understand and that will cost us trillions of dollars—only to give us more of the same.

All we need the government to do is to craft legislation that will level the playing field between doctors, plaintiff’s attorneys, and the huge insurance companies. Then and only then can real and meaningful reform take place with physicians leading the way.
For this to happen however, will require real tort reform, which should include penalties for frivolous lawsuits, loser pays costs and damages, amortization over lifetime of awards, caps on awards, and limits on contingency fees.

To reverse the specialist to primary care ratio that exists today, the government (both state and federal) could offer loan repayment incentives, tax credits, and interest free or low interest loans for physicians--especially primary care docs to open practices. They would be protected from predatory and monopolistic practices by the insurance companies who should actually have nothing to do with them as most patients should be paying for their routine primary care out of pocket. They would negotiate and set prices through free market principles and could negotiate with patients and employers individually or through IPAs.

The states could also mandate that the insurance companies would have to pay "any willing provider" that the patient chooses to see.

The over abundance of specialists would work itself out through market forces...the better ones would succeed, some would retire, and others could change professions or practice primary care.
Insurance companies could be required to only cover uncertainty (as it was designed to do) and especially calamitous uncertainty, like a house fire or a car wreck or an MI or costly procedure(s). Routine visits, routine meds, and screening exams should be paid for out of pocket--giving the patient some responsibility in their care. Insurance companies could provide more coverage for routine care if they wished and patients could elect to buy such coverage, but it would be a traditional indemnity type policy where the patient pays out of pocket and gets reimbursed by the insurance company.

Specialists could continue to be employed by the hospitals or HMOs and/or concentrated in certain “centers of excellence” if they wished and the insurance companies would only be required to pay for this aspect of care--high cost, high-tech care and only if medically necessary. Not just because it is available or just because the patient and/or the media wants it.
True reform can happen and for it to happen it will require work and commitment on our part (which we know well)...which means being available to the patient and providing excellent service AND a quality product.

I am successful because I see people when and where they want me to see them. I see the patient that has insurance and tries to get in to see his PCP only to be told he can't get in or to go to the nearest ER or Urgent Care. And when I do see them, I see them with a smile on my face and I do everything I can within my power to not make them wait! If they have to wait more than a half hour to see me or any of my providers (which is extremely rare) we offer to discount their visit or give them a free visit. If they want to be seen in the middle of the night, I or my providers arrange to see them in our offices or in their home--just like the old days. I can often learn much more from seeing a patient in his or her own environment than I can by performing a 30 minute H&P in my office and without asking a single question. But that is not the point, the point is, that we have shifted care from a provider friendly venue to a patient friendly venue....and that takes extra work and commitment..but it is well worth it and our patients love it.

Today's patients want us to know that they are not just passive participants in their health care--they expect us to respect that their time and needs are just as important as ours.
We all know you can be the smartest and ‘best doctor in the world’, but if your service is bad , it doesn't matter much...and that goes for the office staff.

The old-timers called it the three As--affordable, affable, and available and it is just as applicable today as it was 50 years ago. Unfortunately, we have become anything but the 3As--although I have heard (and used) a few pejorative terms that start with A to describe some doctors (including myself) today.

We can affect reform, but it will not come from marching to Washington or writing letters to congress or closing our offices. It must come from within—within each of us and within the profession. It can be done.

John R. Vigil, MD, FACPE
CEO and Medical Director
Doctor On Call