How will doctors handle the flood of newly insured patients?

If you think health care is expensive now, wait until you see what it costs when it’s free.
-P.J. O’Rourke

I distinctly remember that in first grade I had an idea of breathtaking wisdom and profundity. Candy should be free. You may have had a similar thought at the same age. This idea was supported by an incontrovertible rationale, namely that I really liked candy. Tragically, it only took a moment for my parents to expose a flaw in my otherwise revolutionary scheme. They suggested that if candy were free, no one would bother making candy. All candy makers would do something else that allowed them to make a living. Thus exposed to the painful realities of life, I put the thought out of my head for about forty years.

But now I realize that modern bureaucracy makes my vision more possible than ever. Candy makers obviously won’t work for nothing, but they could be paid to give away candy by a national program (Candycare or maybe the Affordable Candy Act). Employees through their work could contract with third party payers (like Blue Candy) to pay for their candy needs. Thus candy would still be free to the consumer and no first grader would ever have to be denied his gummy bears.

Complications may still arise in this ingenious scheme. Prices, after all, play a critical role in marketplaces. They reflect the resources consumed and risks taken in producing a product. They force consumers to make important decisions about what they need and what they can do without. And they encourage conservation. The only reason we don’t all buy the most expensive product in any class of products (cars, houses, shoes, whatever) is because we’d rather do something else with the money we save. Prices also give producers a powerful incentive to improve quantity and keep prices low, that is they cause competition between producers.

In the absence of prices, all these details become corrupted in our otherwise idyllic candy utopia. Customers would demand more candy than they ever ate before. They may simply eat more candy, but much would just go to waste. If it’s free, no one will stop to think about whether they really want another Snickers bar. Attention to quality would also decline for two reasons. Consumers would not be able to pay more for better candy, so they would have to be satisfied with whatever they got. And candy makers would no longer have to compete since they would suddenly have all the business they could handle.

There would be a dramatic imbalance between supply and the very high demand. Economists call this imbalance a shortage. Long lines would form at candy stores and supplies would not last until the end of the day. Lots of people who previously were content paying for their candy would now not be able to get any. And though the costs to the consumer would be zero, the cost to society would keep escalating as candy makers would consume ever more resources trying to meet a bottomless demand. In a few years candy would become both mediocre and, for society, disastrously expensive.

Sounds familiar?

Healthcare in general, and especially primary care, is operating in exactly such a system. I’ve been writing for years about the shortage of primary care doctors that will happen as the baby boom ages. But with the implementation of the Affordable Care Act (ACA) looming in 2014 the shortage promises to worsen dramatically and is receiving some media attention.

An opinion piece in the Wall Street Journal warns that 30 million people will acquire health plans starting in 2014. The article predicts “the result will be gridlock.” Waits for care will lengthen, and many practices will close to new patients. The author predicts that concierge medicine will grow rapidly as patients flock to doctors who promise them attention and access. I urge you to read the very sobering article.

A recent Medical Economics article asks how an influx of 30 million patients will impact primary care. New physicians certainly will not be trained in time. The article suggests various bureaucratic solutions and states “nurse practitioners know they are about to be elevated in the national healthcare dialogue.” This is jargon for “patients should not expect to see a doctor.” The article warns that in Massachusetts, a leader in experimenting with universal health insurance, only half of primary care practices are accepting new patients.

Finally, The Doctor’s Company, a medical malpractice insurance company recently released a survey of 5,000 physicians to measure doctors’ opinions and thoughts about the coming ACA implementation. 60% of respondents thought that the increased patient volume will hurt the level of care they can provide. 43% said they are thinking about retiring in the next five years. And nine out of ten said they would discourage friends and family members from pursuing a career in medicine.

Sooner or later we will be forced to rediscover the credo that there’s no such thing as a free lunch. Shifting costs from one person to another doesn’t lower costs. A central plan to make something affordable always makes it unaffordable.

Until then, patients should find a primary care doctor who they really like. They should do so right now. And they should ask frankly how he or she plans to handle the coming wave of newly-insured patients. And now that I’m thinking of it, they should buy him some candy.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • http://www.facebook.com/barbara.glickstein Barbara Glickstein

    We can live without candy not access to health care. For all those people facing this dilemma I am not sure they’d appreciate your sugar coating the benefits of the ACA. May I also suggest that those 30m people seek out the primary care services of advanced practice nurses and PAs for their primary health care needs. The mounting evidence supports their role as part of the new landscape addressing American’s healthcare.

  • Beej47

    I’m surprised at your non-caring attitude. What do you propose to do with the 30 million? Just discard them because they can’t pay your exorbitant ‘fee for service?’ 85% of people seeing an MD don’t need to see an MD. Healthcare as we know it is going to change because our current system is broken, in part because of elitist attitudes like yours.

    • cnshap

      This horrific article turns my stomach. Thankfully, the commenters give me some hope for the medical system and the country. Perhaps physicians and hospitals will one day provide only rational, evidence-based care–that should free up a lot of resources.

      • Molly_Rn

        I agree. Perhaps Dr. Fuchs should reassess his choice of occupation. He doesn’t have the heart for it.

        • http://www.facebook.com/jayfagnano Jay Fagnano

          I have been a patient of Dr. Fuchs for a number of years now. I have/had a number of health issues – diabetes, melanoma, dizziness, gastrointestinal issues…… there is no better or caring doctor than Dr. Fuchs. He was born to be a doctor and truly cares about every patient he sees – believe me, he has the heart for it. I travel a lot for work and have had a couple of episodes while on the road – Dr. Fuchs has diagnosed the problem over the phone better than the Hospital Emergency room could do standing in front of me. What I need is the ability to make health care and insurance decisions for me and my family on my own. What I don’t need is a one-size-fits-all national health care program that forces things on me that I, or my family, don’t need. What I fear is that Dr. Fuchs, and other doctors like him, will change their occupation when government mandated healthcare is forced upon them. This is not a “Republican conspiracy” issue – it’s just common sense. I disagree with the claim that people won’t go to doctors more when it’s free – logic tells us that this is just not true. Name anything else that people don’t flock to when it’s free.

          • rswmd

            Nobody’s forcing “government mandated healthcare” on Dr. Fuchs.

          • Molly_Rn

            Hi Jay, glad he has been an excellent
            doctor. However most physicians are reluctant to diagnose over the phone as it
            is too easy to get it wrong without seeing the actual patient. No one is
            forcing anything on you. With Medicare, which I have, nothing is forced on me.
            The payments just come from CMS and I don’t have to fight a healthcare
            insurance bureaucracy to get care and my physician and hospital get paid with
            less hassle. The really cool part is I have insurance and can get healthcare
            and don’t have to plead my case to someone, paid by the insurance company to
            deny me benefits, that I will die if I don’t get the care.

    • technoreaper

      AMEN!

  • henrva

    As a previous commenter noted, we do not need candy to live, but we certainly do need health care. What you and the op-ed piece in the WSJ failed to mention is that as more people have access to routine wellness and preventive care, our population will become healthier. Wellness visits are certainly less expensive (in time and money) than responding to the acute effects of untreated chronic diseases. A robust preventive medicine approach will lower health care costs over time. And you really think you can make the supply and demand argument about care, and then expect us to believe the same won’t apply to the supply of doctors?

    • LeoHolmMD

      I think you are overestemating the effects of prevention. Despite the infusion of loads of “preventive medicine” health care costs continue to rise. Some things are prevented, only to have other ailments take their place. Even the preventive medicine crowd is begining to understand they cannot sell their wares under the banner of “cost saving” any more.

      • henrva

        I don’t expect preventive medicine to solve the whole cost problem, but it is certainly part of the solution. People are always going to get sick – this is a fact of life. I believe wellness and preventive care will allow doctors to work smarter and more efficiently treat patients. It also makes individuals more responsible for their health. To say, “Our doctors will be too busy to see us if we allow the masses access to care so we shouldn’t let them in the door” is not a viable solution. It is blatant fear-mongering. How about finding a solution to the back-breaking amount of paperwork doctors must do, so they can spend more of their time doing their jobs?

        • LeoHolmMD

          Agreed. I think the fear mongering is also overestemated and is not producing the desired effects, i.e more providers. And please, if you can get me out from under all this sorry paperwork, I will gladly see more people.

          • Molly_Rn

            Having one provider, Medicare for all, would mean you got paid, only one set of paperwork and no need to rebill over and over (costing you more that you are owed).

          • LeoHolmMD

            Medicare for all is not a bad idea. We would need to do a lot to improve it and make it more accountable. CMS has done plenty to create extra work for providers and impair care delivery.

          • Molly_Rn

            CMS needs a lot of work too, but it could be done and should be done. We need healthy working tax paying citizens.

    • buzzkillersmith

      No way. Preventive care does not save money in most cases. It improves life quality and is often cost-effective compared with a lot of what we do, but save money–no. That’s crazyhappypundittalk, evidence-free.
      More prevention leads to a lower death rate leads to longer lives leads to more heath care costs. Sad but probably true. What would lower health costs is executing all Americans at age 65. Now that would in fact be preventive, but I don’t advocate it, given my advancing age.

  • rswmd

    So let me get this straight: it’s bad for people to have insurance because then they might use it, but it’s good for people not to have insurance so they have to go to the ERs for basic care, bringing on the collapse of the trauma system as docs and hospitals provide care that they don’t get paid for.

    Makes sense to me.

  • spritelymiss

    While your childhood example certainly brought a smile to my face (I remember having similar thoughts as a little one ;-) , I’d have to give your analogy a fail in terms of comparability. While consuming candy is an enjoyable treat, one that most of us would certainly partake of more frequently if weight & health issues were not a concern, health care consumptions is neutral to unpleasant at best-certainly not a “good/service” that most people would consume/pursue unless it were truly warranted/necessary. There’s an inherent and unique set of “costs” built into the consumption of all healthcare (time, frustration, hassle, discomfort) that serves as a check on consumption in much the same way that price serves as a check to the consumption of luxury goods by mass market consumers.
    My analogy: (time/hassle/frustration/discomfort) are to (healthcare consumption) what (price) is to (candy/purses/cars), etc. In other words, people won’t go out and consume mass quantities of healthcare because it’s free. People do not enjoy going to the doctor in the same way that they enjoy consuming other goods. It’s a responsibility and obligation for most of us-not a fun adventure.

  • buzzkillersmith

    I’m a dumb family doc, not a rocket scientist, but I’ll tell you how a lot of docs will handle it- they’ll close their practices to new patients, except for the ones whose insurance pays top dollar. You can’t fit 15 pounds of sugar into a 10 pound sack. Close your practice and the whole mess becomes somebody else’s problem- the local hospital administrator’s, for example, whose ER is now even more clogged with ear infection cases. But who really likes that guy anyway? Over the past three decades America has willfully destroyed its primary care system ( and is continuing to do so as I type this) and the chickens will soon come home to roost.
    But seriously, I’d like to take more patients, but I can bare cope with the ones I already have. A lot of PCPs feel the same way.

    • southerndoc1

      One possible bright side is that this could actually bring enough market forces to bear that, with enormously increased demand, pay for primary care finally increases.
      But I’m sure the AAFP, in combination with CMS and the large insurers, will insure that doesn’t happen.

      • georgia

        We just need to stop paying to train so many specialists or pay them less. Once we shift away from procedure based payment this will start to happen quickly and I expect that specialist will start churning through more patients to keep their income up. Honestly does anyone deserve more than $150,000 a year? How much does the President of the US make? (btw CMS pays for their residency and internship to the tune of 100,000 a year)

    • technoreaper

      LOL, maybe the AMA should start instructing medical schools to train more doctors. That wouldn’t be good because then your salary would decrease, wouldn’t it?

    • Richard Sanders

      What do you think causes the clog? The claims not going through? The office needs more staff? Maybe another doctor in your office with you?

  • http://twitter.com/skincancerguru Ian Katz

    This is rubbish. Australia has universal healthcare insurance and there is minimal overdemand.

    • technoreaper

      Probably because they train enough doctors. There is a reason this country has to import so many foreign doctors, lol.

  • http://twitter.com/jimocarroll Jim Carroll

    With cigarettes nearly ten bucks a pack, who can afford to pay for their own health insurance?

    • technoreaper

      Not all of us smoke.

  • Molly_Rn

    PJ O’Rourke should just stay drunk. He thinks he is so clever but he is just a drunk. How can having healthcare available to all be a bad thing? Only a drunk would think that. My husband, an emergency physician, is a fan of universal healthcare, then at least he would always be paid and people wouldn’t wait till they were half dead to get help. They would see their family physician and the care would be inexpensive because it would be early in the illness or injury, not the most expensive care possible in the ED. Perhaps Dr. Fuchs should travel more, see how other countries are doing; he will be shocked that catastrophe has not struck in countries with universal healthcare.

  • http://twitter.com/AlbertFuchs Albert Fuchs

    I’m delighted that my post sparked a discussion. Let me
    briefly respond and I’ll be happy to read further comments.

    A few of you noted that candy and healthcare are not
    comparable in importance. Of course. My point in the analogy (besides using a
    lighthearted and true example from my youth) was to show in markets in which
    prices are free to reflect supply and demand prices tend to fall while quality
    improves. In markets in which prices are kept from moving freely shortages,
    rationing, or poor quality result. To those saying “We don’t need candy, but we
    need healthcare” I answer, of course. If healthcare is much more important,
    should we not distribute it through the means most demonstrated to yield
    excellence and affordability?

    Beej47: I agree with you that our current system is
    broken. If you’re willing to devote some time to my answer of what I’d do about
    our current system, take a look at my attempt to explain the problem and offer
    a path forward. (It’s not short. It’s in 4 parts.) The Healthcare Meltdown http://www.albertfuchs.com/blog/?p=260

    LeoHlmMD and buzzkillersmith: Precisely. Preventive care
    leads to better and longer lives, but costs more. I would want it for myself
    and I order it for my patients but we shouldn’t delude ourselves that this
    saves anyone money.

    Ian Katz: I’m not familiar with the Australian experience
    but would be happy to read more if you provided a link. For my assessments of
    countries whose healthcare systems I am familiar with, see my response to
    Molly_RN below.

    Southerndoc1: I agree with you that the insurers will try
    to hold down PCP reimbursement. The money just isn’t there. But if patients are
    willing and able to pay for it, that might be a better way.

    Rswmd: Going to the ER is not the only alternative to
    universal insurance. Insurance isn’t the solution. See my answer above to
    Beej47 for my proposed solution.

    Molly_RN: I think traveling more is a great idea!
    Catastrophe is striking in many countries because of their unaffordable
    healthcare system. The British NHS remains wildly popular, but complaints about
    quality and delays mount while costs continue to explode. Canada has at long
    last allowed patients to pay privately for care, circumventing the long waits
    of their overburdened system. Greece, Italy, and Spain certainly are examples
    of the catastrophes you haven’t noticed.

    • Molly_Rn

      Funny you didn’t mention: Sweden, Denmark, Norway, Finland, Germany, France, etc. etc. Been there doing better than the US.

      • http://twitter.com/AlbertFuchs Albert Fuchs

        Sweden has been slowly transferring more of the cost of care to patients in an attempt to control costs. The doctors in Germany went on strike a couple of years ago. In France in a heat wave about two summers ago hundreds of older people died because doctors were on vacation and no one cared for them.

        Also, please tone down the snark. I don’t presume you’re evil and I don’t think you’d be using such impolite language if we were having a nice chat in person. Hiding behind a keyboard and an alias doesn’t absolve you of using manners.

        • Molly_Rn

          I am not using an alias and I meant what I said. It isn’t snark. You seem to belong to the Republican contingent on healthcare.

          • technoreaper

            Most of the physicians on here come across as such Molly.

          • Molly_Rn

            that doesn’t make it right, just thinking about their pocket book instead of patients.

          • technoreaper

            Most doctors can’t manage their money and are some of least street smart people I know. In this profession, they are encouraged to be selfish and arrogant. Most of these guys are out of touch with reality, and think they are legends in their own mind. They make me sick.

          • Molly_Rn

            Not all physicians are Republican money grubbers. Many are liberal, patient centered and caring. Personally, I know lots of the good guys. Also think about Physicians for Social Responsability and Doctors without Borders. Lots of good guys (male and female) out there.

          • technoreaper

            Obviously not all, but there are a lot of self-centered, man-children out there without a heart, unaware of the privileges they received that enabled them to become successful doctors, privileges other people didn’t have.

          • Molly_Rn

            I know lots of docs that made their own privileges by really hard work. Their parents had little or no money and were blue collar families.

          • technoreaper

            Doubt that is entirely true.

  • technoreaper

    I don’t think health care should be free. However, I don’t think it should be the ripoff that it is now, and I think that the American Medical Association and US universities should stop discouraging students from majoring in science fields and from going into careers in medicine, just to get their members a bigger salary. Clearly, we will be seeing more foreign doctors, or the games will have to end at universities and medical schools. Even the students that make it through all the weeder classes usually get turned down at medical schools unless their dad graduated from the school too. Let more in! If the demand is increasing for health care, the supply will have to as well, duh. Make people pay out of their own pocket for care, but stop encouraging the ripoff practices like charging someone $84,000 for treatment of a snake bite or $2,000 for an ambulance ride for a perfectly healthy man that just saved a boy from drowning.

  • georgia

    Hitting ourselves on the head is also free but i don’t see people rushing out to do it? Healthcare is not or shouldn’t be a discretionary consumer item. People are not widgets. I have to wonder about the critical thinking skills of the writer – does he think that the patients are sitting on a shelf someplace? People are not widgets. If your logic was true than the solution is to cover less and less people and cut down on your busy workload. Oh wait people would suffer and even die prematurely? Well that might be better then the 98,000 deaths a year that happen from preventable errors and infections in the hospital?

    Although many people who are uninsured are the young healthy who aren’t going to suddenly show up for fun, many are those with serious chronic conditions who can’t get insurance under the current system are already in the system but they often present with far worse problems than if we were able to treat them earlier.

    The Dartmouth Atlas studies all show that MASS has the highest rates of provider driven utilization in the country. If they say patients at the same rate as say Mayo does there would be more than enough providers. .The only problem in MA is that there are way to many specialists.

    Shifting costs? Um what do you think we are doing now Most doctors are shifting their workload to focus on those with the most complex problems and places like Group Health visits are now almost 45 minutes long for patients with chronic conditions and up to 40% of the other visits are quickly handled via email or phone encounters.. Do you have an EHR? Do you use physician extenders like NPs? There are solutions out there for those willing to change.

    NO FREE LUNCH Remember who paid for you to get your training (residency and internship for 4 to 11 years?) – Medicare and Medicaid invest on average $100,000 a year to train 95% of US doctors (9 billion a year) Are you going to pay back your US govt paid for education? It is about 500k to 1.1 million plus interest.

    Sadly doctors do think of it as a business now – Less than 4% of US doctors go into primary care (again paid for by Medicare and Medicaid dollars) and we spend triple what any other industrialized country does on health care (and they have better outcomes) so I hope the Luddites in the system retire as soon as possible and we can start with a fresh crop.

    • heardoc345

      To say that the government “invests 100,000 dollars yearly” on a resident igmores that a) that resident worked his butt off for that money, b) indirectly more than made back that money by providing clinical services and c) actually saw even half that money. I’ll return my “government investment” as soon as every ineffective politican returns their legally obtained contracted salary, or as you call it, ‘government investment’

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