Friday, April 2, 2010

New Health Care Isn't What This Doctor Ordered

Preface: From time to time, I reprint articles written by doctors when the articles strike my fancy and have something important to say. This appeared in the April 1 issue of USA Today. In essence, it says universal coverage without universal access if meaningless if there are no doctors around to accept Medicare and Medicare patients.

By Marc Siegel, MD

"While President Obama and Democrats in Congress are running a victory lap to celebrate passage of health care reform, many doctors are less pleased, to put it mildly. More than 40 local and national medical societies representing over half a million doctors came out against the health reform legislation.

I am one of those doctors who believe the new law is bad for doctors and, therefore, patients. Unfortunately, no one has listened to us. So get ready, America. Here's how I see health care changing under this new law:

Insurance premiums are bound to go up as patients with pre-existing conditions are covered. We've seen this time and again, most recently in 2006 after Massachusetts passed universal health insurance. If Congress institutes national caps on premiums, private insurers will need to cut services to maintain even slight profits. If at the same time, Medicare is gutted by half a trillion dollars — as the new law intends — a decrease in services and reimbursements will follow. Private insurers will follow Medicare's lead.

The bottom line: I will be seeing more patients for less money amid increasing federal oversight and an inevitable restriction in services. This will be a disaster for doctors like me who are struggling to keep offices open as expenses soar (nearly 20% annually over the past nine years), as well as doctors just starting out, often saddled with hefty student loans.

My waiting room is already filled with patients whom I see more for a sense of personal satisfaction than any recompense. Take one recent morning. My first patient was a Medicaid recipient whom I have been seeing gratis for five years. I stopped filing Medicaid claims and dropped out of Medicaid because the time to file paperwork and collect wasn't worth the meager payment.

My second patient was an older gentleman on Medicare, which pays me 80% of a predetermined fee. So I receive $56 to care for him. Because he doesn't have secondary insurance, I sometimes write off the remaining 20%. Over the past 10 years, his list of ailments and medications has tripled. His care takes longer, but the fee remains the same: $56.

My third patient is self-employed and struggles to pay his ever-rising insurance premiums. New York, where I practice, has among the highest premiums in the nation because of a 1992 law that made it difficult to exclude patients with pre-existing conditions. He now might benefit from a federal subsidy or qualify for Medicaid, but I'll be unlikely to keep him as a patient. I am in the process of dropping out of low-pay HMOs, and I am unlikely to sign up again with Medicaid unless its reimbursement rates quadruple.

In my office of the near future, I envision losing longtime patients. Sure, my waiting room will quickly fill with more insured patients, but they will likely carry insurance with more restrictions and denials.

Many doctors are already stretched to the limit and will not be able to work with these changes. More will soon accept only cash or checks, creating a two-tiered system of care. And then there's tort reform, or a lack thereof. Without it, I can still be held liable for a bad outcome even if a diagnosis was missed because the insurance denied the test or procedure. Doctors will walk away from this nonsense.
Without the doctors to take care of these patients (the Association of American Medical Colleges estimates a shortage of 160,000 doctors by 2025), the health reform efforts will fall flat.

I hope the new law doesn't play out this way. But this is my diagnosis, and mere optimism won't change the reality of health care in America. Only good reform will, and that's not what the president or Congress delivered.

Marc Siegel is a practicing internist in New York and a member of USA TODAY's Board of Contributors.

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