There is a Chinese proverb that is both a blessing and a curse. The blessing is, “May you live in interesting times,” and the curse is, “May you live in interesting times.” All of us would like things to stabilize into a constant, comfortable and predictable environment for us to live our lives, raise our families and care for our patients. We are entering the most complex and challenging period that medicine has experienced since the 1960s when Medicare was introduced. From now on, everything we have come to know and are comfortable with in our professional lives will change.
Explore This IssueSeptember 2011
Much of this has to do with a law of nature, that of unintended consequences. It states that the desired result of an action, which may have been well intended, well thought out, and justified, may lead to future events that were neither intended nor foreseeable.
The current health care reform bill, the Patient Protection and Affordable Care Act (PPACA), is well intended, has the input of many bright people and was justified because of our failure to provide health care equally to all Americans. Yet it may have the dramatic, unintended consequences of bringing about the demise of private health care as we know it, creating a monumental power struggle and laying the groundwork for a single-payer system.
I would like to explain support of the first element of the premise: that of need, justification and good intentions. The current increase in the cost of health care is unsustainable at 17 percent of gross domestic product (GDP) and growing (Congressional Budget Office. “The Long-Term Outlook for Health Care Spending.” cbo.gov). Something had to be done. According to the U.S. Census Bureau, 30 million citizens did not have insurance or could not obtain it during a two-year period (politifact.com). This statistic implies that they did without health care, but did they? In large metropolitan cities like Memphis, where I practice, the underinsured and uninsured are cared for by the teaching services of the local medical school, county hospitals funded by community taxes or the kind hearts of private physicians. In rural areas and those cities without a medical school, these services are frequently deficient. Those who have lost a job that provided insurance are chronically unemployed or are uninsurable because they suffer from a chronic illness are forced to use Medicaid, Supplemental Security Income or charity services. These patients receive care, though the press suggests that they do not. I know I was part of the safety net system. It worked but was stretched thin and was just not viable for the long term.
The PPACA creates structure and laws that provide insurance for 94 percent of the legal residents of the U.S. (Wingfield B, Whelen B, Herper M. “Health Care Reform Winners and Losers.” forbes.com). It also removes all preexisting condition prohibitions for insurability, extends insurance to our children on our policies until they are 26 years old and creates guaranteed access to health care insurance for almost everyone via exchanges.
The Numbers Speak Loudly
Unfortunately, these changes come with three major unintended consequences. The first is the hidden cost burden placed on physicians and patients to pay for the reform. According to the Congressional Budget Office, the cost of the health care reform will be 940 billion dollars in the first 10 years (Jackson, Jill, and Nolen, John. “Health Care Reform Bill Summary: A Look at What’s in the Bill.” cbsnews.com). Have you wondered how it will reduce the deficit during that time? Remember that the government currently pays for 45 percent of all health care in the U.S. and will pay more in the future (http://en.wikipedia.org/wiki/Health_care_in_the_United_States). Cuts in payments and services will save the government money, and the sources of payment for health care reform will come mostly from taxpayer dollars.
The second unintended consequence is the destruction of the private insurance industry, which today pays many physicians for their services. How will this work? Many firms are finding it more cost effective to pay the penalty rather than offer the health care insurance that they currently provide. You have likely read about the 125 major firms that have requested and gotten a waiver from that part of the law (Morris M. “Health Care Waivers Being Abused by Companies.” Insurance News).Thousands without the political clout of the bigger firms do not qualify for these exemptions. This will force hundreds of thousands, if not millions, of previously covered lives into the health care exchanges. These exchanges must offer four tiers of coverage at different premium rates.
Accountable Care Organizations (ACOs), the creation of Elliot Fisher, MD, MPH, of Dartmouth University, were intended to reduce Medicare expenditures by offering discounts back to Medicare for services performed by physicians or hospitals and then splitting the savings with the providers. The PPACA authorizes the formation of ACOs in all states. Other structures are insurance exchanges that will allow everyone to have affordable health insurance. To be a member of the exchange, or to be on the provider list, physician-providers must accept significant cuts for their services. Remember the old health maintenance organizations (HMOs)? The exchanges will demand the same discounts from providers as ACOs will and HMOs did and will be able to offer premiums to the public at far lower rates than the traditional insurers of today. Several executives of these traditional firms foresee the vast majority of future polices being written by the exchanges. There will be cutthroat competition, mismanagement and possibly fraud among the exchanges, like we saw with the managed care organizations of TennCare (Chang, Cyril F, and Steinberg, Stephanie C. “TennCare Timeline: Major Events and Milestones from 1992 to 2009.” healthecon.memphis.edu/).
Private insurance policies, which will continue to become more expensive because those companies will no longer be able to spread risk over a large enough number of insured lives, will become too expensive even for the rich. They may not survive as they are today. There will be diminished care through the exchanges, less reimbursement for providers and reduced public access: Yes, you and I will demand universal health care from the government.
The third unintended consequence would be threatened physician survival. To counteract this, be positive, be smart and fight. Merge into larger groups, form partnerships with hospitals and, yes, with insurance companies to cope with unbearable costs. Most importantly, whatever you do, change the way you practice to be more cost effective and deliver higher quality, to ensure that you are on the provider list of the exchanges or ACOs. The actions that have led to these consequences of dramatic change, massive cost burden and threats beg the question, “Were all these really unintended consequences?” ENT TODAY
Disclaimer: The opinions and views expressed in this op-ed are strictly those of the writer and do not represent any positions held by ENT Today, The Triological Society, sponsors or advertisers.