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Tuesday, Dec 6, 2022
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Does Health Reform Mean Big Bills, Long Lines?

Much has been said about health care reform, from both sides of the aisle and from many stakeholders. Here with some nonpartisan, nondogmatic thoughts from the perspective of physicians.

Removing many millions of Americans from the rolls of the uninsured is huge — for the country, for the individuals, and for our collective ethical gestalt.

First, do no harm. It’s drummed into every medical student on day one. Physicians are skeptical that we can simultaneously have better quality and expanded access, all at reduced cost. In fact, doctors fear that, in the name of political and economic compromise, the reforms will actually negatively impact quality and cost, while giving a false sense of improved access. These unintended consequences could be enormous — and physicians are afraid for their patients, as well as themselves. It’s unpopular, it’s troubling, but it’s true — there is no free lunch (better access, better quality and reduced cost) and we need to stop pretending that there is.

It’s not health care reform. Never was. It’s health insurance reform. Big, big difference. We’re addressing the issue of how to pay for and regulate health care — and who has health insurance.

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Insurance, whether private or public, does not guarantee an appointment with a doctor. Insurance cards do not equate to care. We cannot legislate more appointments out of thin air. And while there are many technical and procedural improvements that can and should be made, the demands for physicians’ time will outstrip their ability to provide care.

Unable to Keep Up With Demand

Current medical school throughput will not keep up with demand, and the specialty selection incentives are in all the wrong places. We need more primary care physicians, but we fail to recognize that a young resident usually has a quarter of a million dollars in debt — is anyone surprised when many don’t practice family medicine in the rural areas, or refuse to participate in poorly funded programs such as Medi-Cal (Medicaid for California)? Concurrently, doctors worry that, in the name of saving money and without considering possible quality of care implications, allied health professionals will do more than they are trained to do — non-physicians need to complement, not supersede, the doctor. 

Reimbursement matters. Sad but true. Private and public payers are cutting reimbursements to doctors (and hospitals) while the demand for health care simultaneously increases the need for physicians (and hospitals). And while there are always exceptions, in the main, physicians in San Diego are struggling. We lose doctors to other states, we have trouble recruiting new doctors, the average age of practicing doctors is increasing, older (and sometimes younger) docs are retiring early, and physicians are practicing fewer hours per week, thereby decreasing overall available work force hours. Medicare rates for physicians (and only physicians) have been flat for 10 years (before accounting for inflation), and Medicare has thrice gone to the precipice of cutting Medicare rates 21 percent across the board.

Who is in charge in the exam room — the doctor or the bureaucrat? Physicians worry that we will layer yet more regulations, more audits, and more rules on top of an already teetering and inefficient system. We have to ensure that we do not add even more unfunded or underfunded mandates and that we do not blindly subscribe to a mantra that fails to recognize diversity in outcomes driven by the very nature of our patients.

The Terror of Getting Sued

Every exam room encounter is a potential malpractice suit. We have to find a way to address the inconvenient truth that one of the most significant drivers of overutilization is the very real terror of getting sued. The savings and cost reductions from liability reforms come not from lower malpractice premiums for doctors, nor from reduced quality of care, but rather from stopping the insanity of over-testing and over-treating just to avoid an attorney’s letter.

Finally, and probably most concerning to amateur health care economists like myself, is the devil’s brew of guaranteed issue (you can have health insurance, guaranteed), community rating (it matters not what your health status is, you are (within certain limits) going to pay the same as anyone else within your ZIP code), and a weak mandate, (the cost/penalty for not having insurance, remember you can get it anytime you feel a sniffle coming on) is less than the cost of the underlying insurance itself. A weak mandate with community rating and guaranteed issue could very easily lead to a death spiral of increasing costs.

The Hippocratic oath is not a partisan document. It remains as germane today as it was millennia ago. The physicians’ allegiance to that oath, their faith to the patients whom they serve, has often been in conflict with real world, nonmedical forces.

The community of doctors hopes that the benefits of health insurance for 30 million to 40 million citizens offset the costs to American business and costs to the other 260 million Americans, and that increased demand without a concomitant increase in supply does not create long lines for many.

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