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What Change May Come | Jan 7, 2014

Dr. Barry

Obamacare…surely you know I have thoughts on this. It directly impacts my business in both ways…getting insurance for my employees and figuring out how it affects my patients. There is much I know. There is much I do not know. I do know it’s a mess. A big mess and it’s going to get messier from the sounds of it.

Okay, let’s start with the obvious. Before I go criticizing the President and his plan what’s my alternative? I used to think the problem was too big to solve…that unless I devoted hours and hours to the plan I would never get it right or understand the nuances. I thought I would have to spend countless hours listening to the economists and the “thought leaders.” Luckily, as it turns out, it came to me out of the clear blue…of course I think that’s really the fulfillment of the subconscious ramblings and ruminations of my mind until it surfaces in my conscious but call it clear blue if you will. I’ll take it from wherever it may come.

So, my plan is simple…just extend Medicare or Medicade to whomever wants to buy it…don’t make it mandatory. If you have low income you can buy into Medicade. If you have more money, have a job etc., you can buy into Medicare. You have to pay something. You can’t get coverage for free. I don’t have the exact number but roughly 20 cents of every dollar you pay to Blue Cross Blue Shield goes to the paperwork and the processing and the advertising, etc. All those $200,000+ salaries which seem quite nice for a not for profit organization have to come from somewhere (I’m only bitching because I don’t have one of those aforementioned jobs!). Medicare on the other hand charges more like 5 cents per dollar. That’s a huge difference when you are talking about the number of dollars in the system. You don’t need a new tax code or more IRS agents. You don’t need a super expensive website that still doesn’t work more than a month after it’s supposed to be working. You need only expand systems that are already working but need significant reform…not replacement or reinvention.

Libertarians should love my plan because it preserves choice. Republicans should love my plan because it doesn’t set up a new huge government bureaucracy. Democrats should love it because it offers an option for everyone to get insurance. Insurance companies would love it because it still leaves them in the game because part of Medicare…most of Medicare for that matter…involves people choosing between Medicare plans that that are supplemented by the private insurance companies, like Excellus, Atena, AARP, etc. So it’s winner winner chicken dinner but that ship has probably sailed already.

So, even though we don’t really know all the details on Obamacare, we do know a few things:

1. The plan is supposed to provide insurance to everyone
2. The plan is dependent on getting young, healthy people to sign up in order to cover the cost of older people
3. There is no penalty or surcharge for “pre-existing” conditions
4. Part of the plan calls for doctors and hospitals to form groups to “manage patients.” Translation = manage costs

It’s this manage patients part that interests me and should interest you. It’s basically the return of a previously tried and abandoned form of reimbursement called captivation…this was a plan put forth by insurance companies years ago that gives the doctor and/or hospital a set amount of money to care for a set amount of patients. So let’s say that I am given $100,000 to take care of a set of patients for a year…if, because I have a lot of young people who don’t need much doctoring, there is money left at the end of the year I would get some of that as a reward for giving frugal care. If, because I have more patients go to the hospital, or have more difficult to treat diabetics or do more tests, and there is no money left at the end of the year I would be penalized. The name of my practice is PREVENTIVE medicine associates…so I do think it makes sense to order lots of mammograms and colonoscopies and check your labs frequently when you are on blood pressure meds or hypertension meds or diabetic meds. I would rather be safe than sorry.

Also, the part where preexisting illness isn’t penalized is crazy! You don’t pay the same for insurance for a Ford as a Ferrari. Why should a diabetic smoker pay the same rate as a healthy person? Now things like Multiple Sclerosis…that you don’t have much control over contracting would be treated differently. Actions have consequences…so do inactions and I would have an appropriate sliding scale. So Obamacare is going to give medical access to the chronically ill who couldn’t previously afford it…how is this going to cut costs?

Sure, there is lots wrong with the current system. Prices are crazy. More of these expensive tests keep suggesting other even more expensive tests without even giving you a firm diagnosis. Deductibles are out of sight. Non-generic meds cost an arm and a leg. There can be long waits to see the specialist and communication between doctors is still last century. I don’t see how Obamacare can fix these issues. They say they want to focus on primary care and encourage more doctors to go into primary care but for the last decade we have faced a potential 30% cut in Medicare pay each January 1st unless the President signs each year a bill overruling this law. Hard to recruit people to go into a profession that has faced this potential 30% cut in pay annually for the last decade or so. A big distinctive to go into primary care is that specialists make twice the income the primary care doctors make…would even a 10% increase make a difference? Don’t you see a lot of young doctors going into primary care? Not in Upstate New York you don’t.

My profession is under siege. Between lower reimbursements and much more paperwork and pre-authorizations and rising expenses and dealing with the electronic medical records and the daily dreaded risk of malpractice…morale has never been lower. Doctors have been de-selected by insurance companies without warning or obvious cause and with no real recourse. Luckily I am an optimist (of the Lafayette branch) so I have promised myself to always look on the bright side. Just because most can’t see a bright side doesn’t mean there isn’t one. This will be a challenging next few years for doctors and patients alike. Don’t have a thrombo over things you can’t affect. Try and find the humor.

In the meantime, don’t rely on insurance companies or the government or your momma or supplements…take care of yourselves with the old tried and true…diet and exercise. Exercise and diet. Excelsior!