Toward Black Sunday

From an anonymous question in my comments:

Dr Wes, can you explain how this house vote and recon is going to affect doctors? I note that in a MSNBC article they say they'll increase primary care reimbursments for MediCAl to that of Medicare in 2013,so are they leaving specialists, proceduralists out of this deal? where would the Primary refer the patient if speciali(s)ts don't take the MediCAL? Would this reform have impact on doctors pay? Insur, Drug companies, Hospitals all seem Ok with it's passage.

I have no idea what is going to happen on Sunday when the house bill as amended (thanks to Scott Hensley for this link) is voted on. Like many, I have a son who is a recent college graduate working part-time with no health insurance and an incredibly bleak job market before him. While I can afford insurance for him, it is incredibly expensive. I am sure others are not so fortunate. I would be foolish to say we do not have a serious problem in American health care right now.

But I find it interesting how prescient my post on Our Healthcare Hindenburg appears in retrospect now. We are in crisis, just as predicted. We must act. We have a President who has thrown down the glove to his constituents, and if nothing else, should be admired for his commitment at trying to tackle this seemingly impossible challenge. But behind the President, we also have a group with a political philosophy that thinks nothing of ripping up Mieg's field in Chicago because, well, they can. Like the pilot who tried to land there the day after the carnage, we'll be left to clean up the mess. But if the bill passes, no one will want to touch this. Not Democrats, certainly, fearing the results of the November elections, and certainly not Republicans since they didn't like the bill anyway. Who the hell wants to raise taxes and cut benefits for seniors? Are you crazy?

Doctors, despite our relationship with our patients (which will endure), are really mere pawns at this point. The bill appears to throw some money to support primary care physicians, and that's a good thing. But our "leadership" (as defined, almost comically, as the American Medical Association) has endorsed the bill, even though there is no "doctor fix" for the flawed SGR payment formula to physicians. Why? Because to do so would add $320 billion to the current CBO "scoring" of the bill and take the bill over the dreaded $1 trillion dollar amount. (Funny how $940 billion is okay, though). Thank you, AMA, for taking such a firm stand. All doctors are looking forward to the 21% pay cut and are waiting anxiously to see how the AMA will "hold Congress's feet to the fire."

Meanwhile, more predictions coming true: we have hospitals raising rates at an unprecedented rate just to cover costs, despite (at least here in Chicago) some with near record returns at a time of an unprecedented economic downturn. We have insurers, cranking their rates to new heights, crying foul that hospitals are raising theirs. (How unfair!) We have huge corporate displays from medical device, pharmaceutical, and electronic medical record companies at the American College of Cardiology meeting in Atlanta, standing to gain handsomely with the larger portion of insured coming their way. Certainly we would never want to rain on their profit parade - they're just trying to run a business, based much in part on our government-funded health entitlement programs.

Better to publish, conveniently and just before the vote, the inflated salaries of doctors as told by a recruiting company, so those filthy rich doctors can be further slapped into submission for making too much money. Politically, those salaries are easy pickin's, especially if you compare those salaries to their physician-counterparts overseas (just don't mention what it costs to train and insure those same US doctors).

This is not to say doctors have now had a part in price inflation in health care, they have. But the days of ordering an EKG, stress test, echocardiogram and nuclear scan on every patient who presents with chest pain are over. And rightly so. But in a government-developed system that rewards payments for procedure rather than the time spent with a patient, what did you expect? Wouldn't a time-based system make so much more sense? But alas, that would not be productive in the eyes of the business-savvy health care institutions. More time means fewer patients, so sorry, dear doctor, that won't work - take this lower salary instead.

So what does all this mean for doctors? First, doctors will still be seeing patients Monday after the vote. But the effects of the health care reform efforts have already been felt by today's doctors unwilling to wait until the final shoe drops. More and more doctors are selling their practices and moving to the relatively sheltered environs of a large hospital system who, at least for now, will subsidize their salaries because they generate the patient volume for these health systems. Stalwart doctors not bowing to these health systems are turning to a concierge-style pricing alternatives to compensate for the cuts to payment rates received from insurers and Medicare. For those private practice doctors, this model restores a modicum of realism to health care delivery for both the doctor and the patient and makes sense. Look for it to become the norm as these times press ahead...

...at least until state licensure prerequisites prohibit such concierge payments. Then, if the bill passes, we'll all be government employees, one way or another.

-Wes