Worst of the Worst



Worst of the Worst

  I had an interesting conversation about medical care and the implementation of the Affordable Care Act (Obamacare) over the weekend at a family get together. Most of the comments came from my daughter, a doctor, who directs a hospital based pediatric out-patient clinic in the Bronx in New York City and her husband, a solo practitioner in internal medicine and cardiology in Manhattan. Their observations were not encouraging.

  Their shared overview is that the majority of the money being spent and dollars present and future will go towards the bureaucracy, insurance companies, pharmaceutical companies, and trial lawyers. The dollars will not go to provide more and better care. For instance, as hospitals prepare for the new standards, rules and regulations, they are spending large sums of money on training, re-training, and understanding the new rules. Hospitals have to hire consultants to ensure that government forms are properly interpreted and filled out.

  Doctors, in the meantime, have to go electronic records systems compatible with each other. For those who already have electronic systems, this means a conversion that may or may not be financially feasible for a solo practitioner. For with a paper system, the conversion may be too expensive and too unwieldy. Moreover, electronic systems, at least initially, slow down patient processing. Electronic systems, one compatible with the other, are desirable, but neither cheap to install, nor, more importantly, easy to maintain. For those doctors near retirement age, these transitions will not happen.

  The result is a shortage of doctors which is already occurring and will be exacerbated by standard care being offered to the estimated 30 million who will now have insurance. However right this is, it will increase use of the system. What will happen is that more patients will be seen by nurse practitioner or physicians' assistants whose training in relation to a primary care physician is minimal. The new law also provides for a program of medical school graduates moving directly into care positions in rural, remote, or under-served city-center areas.

  In contrast, the standard for a physician today is a college degree, a medical college degree, and three years residency training (with competitive testing at each step). The huge boost in medical knowledge, technology and equipment has also spurred a growth in specialities and sub-specialities which require additional training. As a for instance, my youngest son, a pediatrician, has three years of residency, three years as an emergency room physician, and is in his second year of a three year training for pediatric critical care. He will be 37 when he finishes his "training". His wife, also a pediatrician, has one year of surgical residency, three years of pediatric residency, will have at least three years in general practice, before she starts a three year program for pediatric emergency, her desired field.

  Perhaps minimal training is all that is needed in most instances and at least some professional evaluation is available to those who cannot get affordable care now. And, such a program might relieve pressure on emergency departments which are often overwhelmed by non-emergency patients. However, since no emergency department can turn away a patient, patients might still choose to go where the depth of care is better. My son did have that experience in a city center hospital where the patients by-passed urge-care centers in favor of the emergency departments.

  In addition to the level of care issue, according to my son-in-law, the new regulations call for studies to determine appropriate treatments. This would, he contends, eliminate the use of specific treatments for the minority of patients who only respond to, or are genetically predisposed, to respond to certain drugs or treatments. The majority or consensus, rather than the individual, will rule. In other words, if a certain treatment, not generally effective for the majority, works for you, payment for that treatment would be denied.

  And, there are more regulations to come. I read the first 1400 page Affordable Care bill, and noted then that there are thousands of pages of regulations and specifications that will be initiated by the Secretary of Health and Human Services. Many will control medical practices. The Massachusetts plan, by the way, known as Romneycare, has just initiated a comprehensive control system for all medical care in that state. Under the Affordable Care Act doctors and hospitals must meet certain new standards or face penalties.

  This is not a positive view of the new health care proposals, I recognize, and others could disagree. However, if you're wondering about my daughter and son-in-law's political bent, you might be a bit surprised. As New Yorkers, they lean liberal and democratic party, although my son-in-law is more libertarian. However, he has favored a national third party payer system (Medicare) for years because he believes we owe our citizens comprehensive care. However, he views the Affordable Care bill as containing the worst of the worst and will cost more than can be afforded and with less care being available.