Common claims about predicted physician shortages, health care benefit cuts by businesses, rising co-pays for emergency department services, and lack of primary care physicians under Obamacare have impacted our health care system for decades
One of my favorite passion plays unfolds on CNBC from time to time. It usually involves a CEO of a company that has risen mainly because the market itself has done very well. He or she is revered and called a genius. A few months later, the stock begins to plummet, and the same CEO spends the next interview vigorously assigning blame for the stock decline. Routinely, the culprits are the government, the media, the short sellers, and the lawyers. Personally, I think it’s the lawyers, but if the CEOs want to find the real culprit, someone should hand them a mirror. Even bad managers can do well in a good market, and these CEOs simply missed big trends that were obvious to their competitors. Poor insight does not lend itself to effective strategies for sustainability and growth.
Most everything in the ACA are proposals or initiatives that were already underway, started by various constituents in politics, business, and health policy.
In the same way, there are health care leaders who react to changes by hysterically screaming “Obamacare” at the top of their lungs rather than really understanding long-term trends that have been under way long before the Affordable Care Act (ACA). I can certainly understand politicians doing this because facts, although interesting, seem irrelevant to many of them. But educated health care leaders missing the big trends is a harder sell for me. Shouldn’t they be leading?
Let’s look at some those trends that have been occurring simply because we are at an inflection point for the health care system as a whole. The health care system wasn’t always what it is today and has been constantly evolving, especially since the turn of the century. However, today’s changes are happening faster than ever before. The transition to new financial and care models is largely built on large-scale changes in society that include increasing consumerism, greater price transparency, rapidly emerging technologies, hard financial realities, and changes in social demographics. Legislation has little to do with these trends.
The ACA rollout is clunky at best. It has to be changed and surely will be, but most major policy implementations are rocky. What the ACA attempted to do was reverse the effects of a market that allowed exclusion criteria that distorted risk pools so health insurance became either difficult to get or incredibly expensive. Most everything in the ACA are proposals or initiatives that were already underway, started by various constituents in politics, business, and health policy. The ACA has certainly increased the speed of that change, and we all know how much we love change in health care. So let’s look at a few common claims about Obamacare and separate long-term trends that have been occurring and will occur no matter what happens to the ACA.
The law is causing a shortage of physicians!
The truth is that there has been a worldwide shortage of physicians for decades. In fact, this was a concern when I was a medical student (I’m a PGY 34), and we haven’t meaningfully addressed the issue yet. There was a short time when we had additional medical school spots in the 1980s. However, the funding for that dried up. Graduate medical education slots have been decreasing since the 1990s, so we now have medical school graduates waiting for residency positions. Predictions of a physician shortage by 2020 have been a focus of major articles in the early 2000s, but what I learned from my time in Washington, D.C., is that policymakers often don’t want to deal with difficult issues until there is a crisis. Congratulations, here’s your crisis.
The law is causing business to cut health care benefits.
Oh, please. “Business” only got into health care benefits in the 1940s because wages were frozen and benefits were provided to get around the wage freeze and compete for employees. Since health care insurance costs started escalating rapidly, businesses have looked for ways to insulate themselves from those huge variations. We’ve seen businesses move from defined benefits, meaning that they would pay for certain benefits, to defined contributions, meaning that they would contribute a finite amount of dollars to employee benefits and employees could pick from a menu of benefits or pay the difference. This is driving the growth of private health-benefits exchanges. I know of no person, employer, or insurer who wants to pay a penny more for health care. Do you? For business, it is all about containing costs.
The law will cause a crisis in primary care.
In most countries, there are three generalists to each specialist. Therefore, access to primary care is much easier. In the U.S., that ratio is reversed, with three specialists per generalist, putting a squeeze on access to a generalist. That ratio has nothing to do with recent legislation but evolved over time and has become unsustainable. Simply put, specialty care pays well and allows growth in expertise in a narrow area, so physicians have chosen those career paths. We are just now recognizing, and rewarding, the value of those in primary care. Too little too late? In today’s world, most generalists don’t admit patients, preferring to have emergency physicians and hospitalists care for their patients. Let’s take that opening and run with it.
The new law makes people pay more out-of-pocket.
Have you been sleeping? For decades, we’ve seen the rise of the patient as a payer class, but somehow, health care providers have ignored it. The rising copay for emergency department services was created to incentivize people to go elsewhere, despite the fact that they have nowhere else to go because regular physician practice office hours don’t meet the needs of patients after hours and on weekends. Insurance companies have designed benefits with higher copays for emergency departments as “value based insurance,” incenting the patient to go to less expensive care sources.
In 2003, President George W. Bush signed legislation that started health savings accounts (HSAs) and encouraged the growth of high-deductible health plans that had lower premiums and allowed consumers to keep the savings that were not spent in their HSA. The rapid rise of high-deductible health plans over the years has put the “first dollar” coverage on the consumer, essentially making the patient a payer source. This summer, the American Medical Association reported that 23–24 percent of physician payments came from the patients themselves. That trend is likely to continue, and increasingly, we will see patients change their patterns of access to care and their choices of care. Let’s let them choose EM when it’s the best option.
These changes were responses by payers to perceived overutilization of expensive and unnecessary care, creating a move to value-based care and driving growth of retail and urgent care clinics for acute care needs. Let’s face it: the deductibles have gotten so high that patients simply won’t pay large bills. It’s a bit ironic that physicians and hospitals started health insurance back in the 1930s because patients couldn’t afford to pay their bills. Now, we’ve come full circle.
But facing these facts provides opportunity to thrive. I predict that there will still be patients and they will need our care. The opportunity here is to design cheaper alternatives for care by emergency physicians and an “EM team,” anywhere and anytime. If not, I can guarantee you that someone in Silicon Valley or Nashville is working on that solution right now—and at a profit. Now is a great time to lead these changes and redesign emergency care for all of our patients.
Dr. Martinez is chief medical officer and vice president of North Highland Worldwide Consulting and assistant professor of emergency medicine at Emory University School of Medicine, both in Atlanta. He attends at Grady Memorial Hospital.