Access, Physician Shortage - The Ultimate Crisis in Health Reform: Lack of Access

An Interview with John McDaniels, CEO of Peak Performance Physicians, Inc, New Orleans, Louisiana

A: How long have you held your position as CEO of Peak Performance Physicians, Inc, a practice management firm dealing with hospitals of physicians?

A: We’ve been in existence for 20 years, and we manage and consult with hospitals and medical practices throughout the United States.

Q: How many practices do you consult with?

A: Thousands of doctors and hundreds of hospitals. About 1/3 are in the Southeast, 1/3 in the Northeast, and ½ everywhere else.

Q: What do you see as the major issue of health reform?

A: I think the ultimate issue will be access to medical care. If any kind of health plan is forced upon physicians, you will see more and more physicians opt out of Medicare and Medicaid, which will result in waiting times of 2 to 6 to 9 months for Medicare and Medicaid patients. As that happens, you will see a huge public outcry, and they will flood their Congressman and Senators with complaints because they won’t be able to find a doctor. The ultimate problem is to provide access and at the same time compensate doctors and hospitals appropriately.

Q: I notice the AMA came out this week and opposing a public plan and saying it was against the government making it mandatory for physicians to see patients in that plan. Is it possible for the government to mandate doctors must take care of patients?

A: Anything is possible. I think what you will see physicians will simply stop participating in any kind of health plan. They will just be in a private business just like where you go see your hair stylist. Certain things are necessary for people – housing, food, and health care. All other participants in other essential business sectors are reimbursed dollar for dollar. The grocer for food stamps is reimbursed dollar for dollar, the pharmacist is reimbursed dollar for dollar, but hospitals and physicians are not reimbursed dollar for dollar. They are forced to accept a 40% to 60% discount. Where else in our society is someone expected to provide discounted government subsidized services on less- than- it-costs basis? That is just fundamentally wrong.

Q: Well, Senator Kennedy came this week with his plan. He will solve the problem you mention by providing Medicare and Medicaid for all, and out of the generosity of his heart, he will give hospitals and doctors 10% more.

A: The ultimate solution is that if the government really wants to get in the health care business and government needs to find out a way to have its own governmental hospitals, its own governmental physicians. That way governmental patients can go to those governmental hospitals and governmental physicians. Then they ought to leave the private sector alone.

Q: Let’s get real for a moment. How many of the doctors with whom you consult are accepting new Medicaid and Medicare patients?

A: I do not know of any physicians with whom we are consulting throughout the United States who are accepting new Medicaid patients except those they may be treating as inpatients. If you’re on call and a Medicaid comes through the ER, you’re obligated to take care of them.

With regard to Medicare patients, most of our practices are not accepting new Medicare patients, but are continuing to see established Medicare beneficiaries. If this new public plan, if there is one, is worse than the old plan, I think you will see more and more physicians totally opt out of Medicare.

Q: Massachusetts may be a harbinger of things to come. It has achieved near total universal coverage over the last three years, but according to a Merritt and Hawkins study of waiting times for various specialists – primary care, internal medicine, cardiology, and orthopedics – of 15 major cities, waiting times to see a doctor are now 49 days, nearly twice as long in Boston as any other city. To me long waiting times and difficult access are what’s coming down the pike if President Obama has his way.

A: You’re right. All you have to do is look across the border at Canada to see how waiting times lengthen with government medicine. In the U.S, there are other models of universal care. In Louisiana, every citizen is entitled to free care at a teaching hospital. You may have to wait a while, but care is free.

Unfortunately, after Katrina, teaching hospitals don’t have the capacity – the beds, staff, and facilities- to care for them.

This brings up the fundamental point: is health care a privilege or is it a right? If it’s a right, we have figure out a way to pay for it legitimately. If you say to doctors and hospitals, it’s your public duty to take care of people, you’ll have to pay them enough to stay in business. Then you will have a financial death spiral.

Q: President Obama’s problem right now is how to pay for his ambitious $1.5 trillion health proposal for universal coverage in the fact of the federal government’s burden of $100 trillion of unfunded liabilities for Social Security, Medicare, Medicaid, and pension military obligations. People are sitting back and saying – now wait a minute. A trillion here, a trillion there! Where’s it all coming from?

A: Yes, how do you continue to sustain that kind of spending? How do you fund other than through taxation?

Q; Now, wait a minute. President Obama says we’re going to fund it by saving money through prevention, health information technologies, and primary-care based coordinated care.

A; Those are appropriate measures, but the problem with both Medicare and Medicaid patients is they have difficulty being compliant with these things because of transportation, caregiver, cultural, and lifestyle issues. For the most part, Medicaid patients are unwilling to change. You can throw all the money you want at doctors and hospitals to change these lifestyles, but it doesn’t solve the problem.

Q; So the road to financial salvation is paved with good intentions, but the financial hell is still there, and you can’s solve these systemic cultural problems.
The other solution Obama is suggesting that all we have to do reduce practice variations from high spending to low spending regions, and Voila! We will end 30% of waste and cover the uninsured in more impoverished in low-spending regions. What about that scenario?

A: It makes for a good academic discussion. There are different reasons for spending by city and state, and to a limited extent, those reasons may deal with practice patterns. But if try to homogenize care, you’re going to have to protocol how diseases are treated. That leads to the “S” word, namely. “Socialism,” which means you’re told what to do and how to do it.

Q; What is the mood of your physician clientele?

A: They’re despondent, especially regarding any type of governmental plan. I think they will drift towards private medical practices – concierge practices, cash only practices, practices unconnected to health plans. They really have no option. They just don’t have any lobbying power through their medical organizations. The AMA is impotent. The other thing, The vast majority of the public think hospitals and doctors make too much money. They would be shocked to know what the average doctor makes. Doctors can no longer collectively bargain, They are just going to individually bargain. I just won’t participate in Medicare or Medicaid, or I just won’t participate in any insurance program.

Q: And they’re doing it?

A: Yes, they’re already doing it. And it will accelerate, because that’s the only real clout they have. They have absolutely no bargaining power through the AMA or any other physician organization. Doctors are not by nature proactively politically, and they’re just hunkering down. If they, the government, try to cram their plan down our throats, we’ll just have a private practice – cash only.