During
his speech, Noseworthy noted the “tipping point” was the recent 3.7% surge in
Medicaid patients as a direct result of ACA Medicaid expansion. “If we don't grow the commercially insured
patients, we won't have income at the end of the year to pay our staff, pay the
pensions, and so on,” he said. These are
difficult decisions to make by rationing access
to healthcare for the poor. It is a
moral dilemma those of us in independent practices have been facing for some
time.
Mayo
will continue taking all patients, regardless of pay or source, and this policy
exempts those seeking emergency care. This move is attempting to shift payer
mix and mitigate the financial pressure faced by many health systems as a
result of federal health-care reform. Approximately 50% of patients at Mayo Clinic
are Medicare or Medicaid. Higher reimbursements for privately insured patients
makes up for losses incurred treating Medicare and Medicaid patients. Mayo says
these payers reimburse at about 50-85% when compared to commercial
insurance. It is about the same in my
office.
While
ACA Medicaid expansion brought the reality of healthcare coverage to millions; it left behind the practicality of providing access to healthcare for those same
millions. As a direct result of the ACA,
demand for physicians now overwhelms supply, due to increased closure of
independent practices from incentivizing hospital consolidation. Physicians are
not mean or spiteful, but we have families to feed, mortgages to pay, office
rent, employee salaries, malpractice insurance premiums, and last but not
least, student loans payments hanging over our heads. If my office closes, access further declines.
Throwing
millions of additional patients onto Medicaid worsened the quality of care for
those who were already on the program pre-ACA.
Four years ago, my payer mix was 50% Medicaid and while never flush with
cash, I was able to survive. Post-ACA,
the payer mix must shift to 75% commercial and no more than 25% can be Medicaid
in order to mitigate financial pressures. I have been closed to new Medicaid
patients for more than a year with more than 70 families on the wait list.
Prior
to The ACA, America rationed costs by not covering a portion of the population
for preventive services yet mandating provision of emergency care (EMTALA) to
everyone in spite of operating at a financial loss. Our post-ACA healthcare model still rations
care by a variety of mechanisms: price,
(copays, deductibles, premiums), capacity (physician shortages, advent of
independent midlevel providers, certificate of need for facilities), and
utilization management limitations (prior authorizations, referrals.)
Healthcare
has remained a beautiful construct yet dysfunctional machine. Pricing measures reward error, inefficiency,
and poor outcomes, private and public sectors continue to have a love/hate
relationship regarding unbalanced cost shifting, and ultimately, attempts to
regulate this catastrophic system by the government will lead to worsened
outcomes for the poor across the board.
The
American Health Care Act (AHCA) is not perfect, but it is pragmatic. Limited by the budget reconciliation rules to
fast-track for Senate consideration, it was designed to attain 218 votes in the
house and 51 votes in the Senate, which will generate cheers as well as jeers
on both sides of the aisle. The bill is
an important first step toward compromise and away from the disastrous ACA.
The AHCA would significantly expand health savings
accounts, allowing patients to control more of their own health-care dollars,
and give those who buy coverage on their own considerably more choice in the
kinds of plans they buy. This change alone
will allow lowering of premiums. Its refundable tax credit will be available to
low- to moderate-income individuals and will equalize the tax treatment of
employer and individual insurance.
The bill would transform Medicaid into a more streamlined
insurance program: moving decision-making to the states, permitting them flexibility
in dealing with preexisting conditions, provide reinsurance, and trust state
insurance regulators to run their markets.
In my opinion, not providing enough assistance to the poor and elderly
is a fly in the ointment, however this can be adjusted in the next round,
making premiums more affordable for the poor.
The
AMA and the AHA oppose this plan; the importance of which must not be
overlooked. These organizations do not represent
practicing physicians and have very little interest in supporting the
physician-patient relationship. It is
very encouraging to me neither organization was able to garner much in the way
of concessions on their behalf.
When
the AMA and the AHA speak out against a bill, one must consider the AHCA as
likely to be beneficial for both patients and physicians in the long run. Less
than 15% of physicians today belong to the AMA and they pad their pockets by
burdening practicing doctors with excessive regulations. The AMA receives $72 million from licensing
the ICD-10 coding system, a restrictive noose around our necks which increases
costs of running a practice.
The
AHA states they will collectively lose $166 billion dollars if the ACA is
repealed. It is worthwhile looking at who
profited most from Medicaid expansion.
Patients theoretically stood to benefit from improved coverage, but only when access was coupled with coverage, which it was not. Of the $3 trillion dollars spent on health
care, hospital care accounted for 32% ($1 trillion), while one-fourth of those
costs ($250 billion) accounts for salaries and benefits of hospital executives.
The annual average hospital CEO salary is $600,000, while the average primary
care physician makes $185,000 (for the record, I have never even come close to
this amount.) Physicians receive only 8 cents of every healthcare dollar spent.
Do any of those expenditures appear to be benefitting patients? Obviously, the answer is no.
The
AHCA is a very good start, like 100 lawyers at the bottom of the ocean. It does not seem like much at first, however
over time, it will make a positive difference.
Anything is better than the ACA for patients, physicians, and our sacred
physician-patient relationship. When you delve further into the details of the
AHCA, you will find less coverage on the surface, yet more access for the people. It is time to take the power away from the
AMA and the AHA and build a healthcare plan that is pragmatic; knowing there is
no perfect and only compromise, but that is something of which we are in desperate
need.
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