There has been much talk in the media and physician community regarding the Affordable Care Act, well known as ‘Obamacare’ or the ‘Patient Protection and Affordable Care Act’ (PPACA). Many IAPAM (The International Association for Physicians in Aesthetic Medicine) members are concerned about how this new program will impact the health of their patients and the health of their medical practices.
While this new change might be seen as favourable by many patients (or future patients), there still remain a number of unanswered questions. From a patient’s perspective, more patients who have underlying illnesses or significant past medical histories will be offered insurance, enabling them to seek life-saving care in the event of an emergency. However, from a physician’s perspective, things don’t really look that good. In particular, physicians believe that Obamacare will negatively impact their practices and reduce their earnings; a reason why some doctors have already resigned before the changes were due to take place on the 1st January 2014.
The changes that have been recommended are no doubt of concern to physicians. Let us take a closer look at why this is.
1. A reduction in pay
In 2009, the Wall Street Journal reported that Medicare reimburses physicians only ‘81% of private rates’ while other reports suggested that Medicaid only reimburse 56% of private rates (The Wall Street Journal, 2009). In essence this means that physicians lose out tremendously when it comes to receiving their pay. It should come as no surprise that many specialties refuse care for patients who use Medicare or Medicaid, purely due to financial losses they may incur. As expected, this move to utilise private insurance in Obamacare can have detrimental effects on patients as many believe it will resemble Medicaid in a lot of ways. In other words, having healthcare insurance does not guarantee that a patient will be seen by a doctor.
There remain other concerns when it comes to pay that physicians will receive. Currently, physicians working in hospital-based practices are paid more than those who work in independent private practices. This is because the Medicare billing scheme varies between the two. With Obamacare, the rates of reimbursement will be made ‘site neutral’, meaning that irrespective of whether a doctor works in a private establishment or in hospital based practice, they will receive the same pay. And given that Obamacare reimburses doctors at a lower rate when compared to Medicare, it is clearly evident that physicians will get paid less than what they did in the past. It would therefore come as no surprise that more and more medical practices are turning away patients. Health insurance for all, medical care for a few.
Obamacare features a 90-day grace period – a feature not seen in any other healthcare system. As per the policy, patients can undergo expensive and complicated procedures having secured insurance, and then cancel it within the 90-day period, leaving the doctor out of pocket (Powell, 2013). Doctors may need to hire debt collectors and spend their valuable time chasing after patients if this were to happen.
2. Insufficient time spent with patients
Ask any doctor why they became one, and the answer will pretty much be the same – ‘to help the sick and promote their well being’. Of course, one has to earn a living as well when doing so, and physicians would (like any other profession) expect to get paid what many would consider to be an appropriate amount of money for bringing their expertise to the table.
An essential part of providing the patient the best medical care possible is to spend time with them, listen to them and develop a bond of trust so that the right treatment can be administered. Taking a detailed clinical history, performing a detailed clinical examination and prescribing the right treatment takes time; not every patient is the same and many of them have complicated medical problems. Until recently, this aspect of healthcare was not of any concern whatsoever to the doctors, but the Affordable Care Act could make the time spent with patients significantly lower.
With the use of Medicare, physicians may find that spending more time with their patients could result in them being paid less. According to a report published by Jason Fodeman of the Galen Institute, physicians in Manhattan ‘receive $48.92 for a 10-minute follow-up visit, compared to $158.86 for a 40-minute follow-up appointment’ (Fodeman). When calculated as an average on a national scale, it would mean that doctors would suffer a 17% reduction in their pay just for doing the right thing and spending time with patients who wish to have their physician care for them.
This problem does not just extend to existing patients attending follow-up visits; it also can involve new patients who are seeing a physician for the first time. The initial visit between a physician and patient is widely regarded as the most important one – it is one where a bond is created and a platform of trust is generated. The more detailed the visit; the better is the patient-doctor relationship.
Let us take a patient with heart disease for example. Managing heart disease is not just about prescribing medicines; it also involves taking time to discuss with the patient different lifestyle modifications that they need to observe that will prevent them from suffering from heart disease in the future. Healthcare is not just about treatment; it is also about prevention.
The concern of course is that time constraints may make the latter aspect difficult to administer, potentially putting patient’s lives at risk. A study published in the British Medical Journal clearly demonstrated that patients who were armed with information and knowledge about their clinical condition coped a lot better with their illness when compared to those who did not (John G R Howie, 2009). Patient education will likely be placed on the backburner.
3. Breakdown in doctor-patient relationship
The relationship between a physician and their patient is sacrosanct. It is one based on trust, professionalism and confidentiality. In addition, it is also one that is based on time; time spent with the patient. New patients who have never seen a physician before often need more time to be seen. While documentation is important in medical practice, it is not one that is of primary importance on a physician’s mind when they see a patient – it is the conversation they have with them and the treatment that they can offer to help them that matters.
Obamacare requires stricter record keeping, which in addition to problems with pay linked to time spent with patients, means that doctors will have less time to deal with patients and will spent more time buried in paperwork. In a survey published by Jackson and Coker, 66% of physicians who participated in the survey stated that the new law would involve them more in paperwork than at the bedside of the patient (Jackson and Coker). Undoubtedly this can result in a breakdown in this all-important relationship. Some have even foreseen ‘the death of the bedside manner’ as a result of Obamacare (Siegel, 2013).
The implementation of Obamacare could mean an increase in the number of lawsuits that doctors will face in the future. The lesser the time spent with the patient, the higher is the likelihood that important pieces of information in the clinical history and findings on clinical examination can be missed. This could potentially result in a patient suffering from avoidable complications and this could lead to the doctor being sued.
Obamacare now mandates electronic patient records. While this may sound good on paper, there is always a possibility that computing errors and wrong doses are entered into the database. If this happens, doctors could be held responsible and can face a lawsuit.
Indirectly, this could mean higher medical defence union insurance premiums for physicians. It could also mean fewer physicians in the future as bright students could be put off from joining medical schools despite their great desire to contribute to society through the practice of medicine.
5. More patients, less physicians
Given that Obamacare wishes to include the entire United States population to have health insurance, it could mean that there are potentially more patients and a fewer doctors available to see them. Many practices do not accept patients into their practice, leaving them without a doctor if they need medical attention. Irrespective of this aspect, patients will still be able to get emergency medical care in the ER, which will inundate and overwhelm staff there. There is always a possibility that staff could go on strike as a result of the stress that they go through. Ultimately, it is the patients who will suffer and the doctors who will feel frustrated and completely helpless. Family practices will likely suffer the most as more and more patients start to rely on them for timely care in the community
Is there a solution?
It is still early days, but there could be a few changes that could make Obamacare better for people in the United States. One such solution would be to offer care to those people who really need it – insurance should cover patients who have serious illnesses, while private insurance can cover simpler and straightforward health problems. Increasing the budget to train more residents may also be a worthwhile solution, as this will place more doctors in hospital and in the community.
Family practices can thrive through this adversity by developing a ‘family team care model’, which involves a multitude of staff providing patients the care they need (Team Care Medicine). This would mean more time with the patient and better patient satisfaction rates.
Finally, medical practices might be able to thrive by adding a multitude of ‘non-insurance based services’ to their portfolio. These can include aesthetic procedures such as dermal fillers, botox injections, anti-aging treatments, non-invasive body sculpting, and adding non-insurance medically supervised weight management. These procedures are extremely popular and sought after by an extremely large proportion of the population, and are not covered by insurance. This would increase the income a practice is able to make as payments will have to be made directly and immediately to undergo these procedures.
Obamacare promises to make changes that will hopefully help the masses, but clearly there are a number of disadvantages and negative aspects that physicians will face as a result. Lesser time with patients, less pay and a potential breakdown in the doctor-patient relationship make implementation of Obamacare a cause for concern for physicians.
These concerns have produced a desire for physicians to look at alternate, non-insurance based medical procedures. The IAPAM has noticed a sharp increase the in registrations of its cosmetic procedures hands-on CME training programs like Botox/Fillers, lasers, medical microdermabrasion, and non-invasive body shaping; along with their medically supervised weight loss program which is not insurance covered and affects 68% of their existing patients.
Fodeman, J. (n.d.). The New Health law :Bad for Doctors, Aweful for Patients. Retrieved December 31, 2013, from The Institute for Healthcare Consumerism: https://www.theihcc.com/en/communities/policy_legislation/the-new-health-law-bad-for-doctors-awful-for-patie_gn17y01k.html
Jackson and Coker. Survey: Physicians Say Affordable Care Act Will Spike Costs, Impact Care. Jackson and Coker.
John G R Howie, D. J. (2009). Quality at general practice consultations: cross sectional survey. British Medical Journal , 319, 738-743.
Powell, J. (2013, November 13). The fourth Obamacare shockwave is about to reach us. Retrieved December 31, 2013, from Forbes: https://www.forbes.com/sites/jimpowell/2013/11/13/the-fourth-obamacare-shock-wave-is-about-to-reach-us/
Siegel, M. (2013, December 26). The Death of the bedside manner. Retrieved December 31, 2013, from Forbes: https://online.wsj.com/news/articles/SB10001424052702303932504579252770123128660
Team Care Medicine. (n.d.). Family care can thrive in the coming ‘perfect storm’. Retrieved December 31, 2013, from Team Care Medicine: https://www.teamcaremedicine.com/rebuilding-primary-care/
The Wall Street Journal. (2009, April 13). The End of Private Health Insurance. Retrieved December 31, 2013, from The Wall Street Journal: https://online.wsj.com/news/articles/SB123958544583612437