How Obamacare will create a new normal for medicine

How Obamacare will create a new normal for medicine

The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes.

In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.”

Comparing and contrasting with other industries

In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors?

Are we special?

Are we different?

In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations.

What government will (or will not) do

Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of … nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure?

There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ever.  Even the most “harsh” and “cruelest” proposals only call for a decrease in the rate-of-increase, of overall spending.  There never has been any, and there’s no reason to predict there ever will be, any policy other than kicking the can down the road until after the next election, and the next one and the next one. The voters have spoken and they want to spend an extra $1,000,000,000,000 on healthcare.  Santa Claus is in fact coming to town!  That may be terrible for the country, but it may well be very good for doctors; that is the smart ones.  There may be more hoops to jump through, more requirements and regulations, as well as creative strategies needed to get a “piece of the pie,” but demand for doctors’ services will necessarily increase, and tremendously so.  Also, despite much posturing, tough talk and threats of showdowns year after year, the SGR-fix has always been passed and the budget debt ceiling has always been raised.  Medicare expenditures will necessarily continue to go up, and up, and up. More patients will be insured wanting our services. The elderly baby-boom population will be sick and growing older and need us desperately.

I was told a story by a retired physician about his long deceased cardiologist father who practiced before Medicare was instituted.  He tells of his father who was a very compassionate physician, but a staunch free-market conservative who like many physicians at the time vehemently opposed the proposed Medicare system.  His father would say that physicians provided charity care for free to the disabled and elderly all the time and that Medicare was just a Trojan-Horse for socialists who wanted to take over the American healthcare system.  He may or may not have been correct, but ultimately to his dismay, Medicare passed and became law.  All of a sudden and very unexpectedly, his salary … doubled.  He never complained about Medicare again.

The point of this anecdote is not to suggest that physicians’ salaries will double as a result of Obamacare.  They will not.  However, it is to suggest that despite the 2000 pages of regulations and requirements in the cloud of Obamacare that hangs over our heads, there will be an unexpected silver lining, somewhere.  I think we can simultaneously work vigorously to reform our profession, yet shed the “culture of victimhood” that has grown like mold upon physician attitudes and search for positive opportunities.

Some physicians will “opt-in”

Such new opportunities will not be the same as in the dead era of Osler, Hippocrates and Marcus Welby M.D.  Also, I cannot say that chugging along with the same old strategy, expectations, and disappointments of a bygone Golden Age will be a winning plan, either.  It may involve simply being content as a cog in a large machine or “system.”  It may involve thriving in the role of “corporate soldier,” learning how to “play the game” while finding ways to save costs, increasing efficiency for your group or other groups and “promoting” your hospital.  Others may move into the government side of healthcare and find opportunities in healthcare policy planning and consulting.  Clearly, knowing “the medicine” isn’t enough anymore and in fact, seems the least important of that which is expected of us.

Other physicians will “opt-out”

Greater numbers of physicians will find opportunity in opting-out of the system by making their practices cash only, concierge, or declining to participate in Medicare and a more dominant Medicaid system.  Another option may be for more Emergency Physicians and surgeons to exploit technicalities in Obamacare and States with liberal certificate of need laws and open their own centers that offer services for a flat fee outside of traditional government or private insurances.  As more insurance plans require deductibles in the thousands of dollars and refuse to pay for certain services entirely, such centers may gain more traction where they are feasible.

Others may “opt-out” more insidiously.  The new generation of physicians may very well evolve into protocol-following, brown-nosing, corporate mantra-spewing clock-punchers, indistinguishable from other “providers” all while refusing to make the tremendous sacrifices of doctors past, such as incredibly long hours, over-burdensome call schedules with great sacrifice to marriage, family, and personal well-being.  Maybe that’s okay, and maybe that’s what our new Overlords of Healthcare want and will reward.

More primary care physicians and other specialties likely will take the “9-5, no call” route and leave the after-hours hassles to the ED and hospitalists.  More medical students may pick careers in cosmetics over critical care.  More Emergency Physicians may leave high-stress clinical shift work in the Emergency Department for Administration, group management, Hospice and Palliative care fellowships, Urgent Care ownership or anything else seen as less stressful.  More surgeons and specialists may opt out of emergency call for a less stressful life and a focus on elective cases with higher reimbursement to liability ratios.  I see more Anesthesiologist moving to “lifestyle” positions at ASCs doing elective cases, or pain procedures with little or no call.  Many physicians will consider early retirement.

The silver lining

The pioneers of Medicine did not have to worry about our “new normal” of Obamacare and all of its 2000 pages of regulations and requirements.  They didn’t have to worry about $300,000 of medical school debt, mega-million dollar frivolous lawsuits or being fired over patient satisfaction surveys based on complaints that may or may not even be valid.  But they also didn’t have our modern-day luxuries, salaries, exploding technologies, or a nation of patients soon to be more widely insured and in demand of our services than ever.  There is much worth fighting to reform, yet even more worth fighting to preserve.  All things considered, we are tremendously better off.

Be sure, Obamacare will change modern medicine, and it will change it mightily.  Also be sure, that with us or without us, and whether we look forward to seize new opportunities or look back upon shattered expectations, the profession of Medicine will be alive and well, and thriving more than ever before.

“BirdStrike” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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  • Scott

    If we aren’t special, then why does the world expect our services for free? Any of the other professions you listed near the beginning would laugh if you walked into their office and expected them to just give you their product free of charge. So if we are on par with them, then why is anyone coming into the hospital without a valid damn credit card, swiped at the door? The truth is, we aren’t like everybody else.

  • DavidBehar

    Docs always complain but make out like bandits. I cannot get over Obamacare as a patient. There will be no more expensive care. I will just die when I need some.

    Within a short time, there will be a single payer, Medicaid. It will obstruct and deny nearly all care, including the use of cheap generics

    • buzzkillersmith

      Far be it from me to say anything positive (note my moniker), but, as a patient, you might be pleasantly surprised by what the future holds. I really think that the great middle class of America will simply not put up with being Medicaidized. Medicarized maybe, but that is a different thing altogether. They say we Americans do the right thing after exhausting all the other alternatives. I think they’re right. It might take some time, maybe even a decade or more, but my best guess is that almost all of our countrymen will eventually enjoy the same access and quality that other advanced countries have today.

    • John Henry

      And then we will see black market medical care.

  • Randall Oates, MD

    Even before Obamacare, there have been fundamental changes underway in the industry that is about to derail the fee for service gravy
    train. It is time for physicians to make one of two choices…

    1. opt out and go the direction of Direct Care or Concierge

    2. Become part of some sort of integrated delivery system able to manage the data expected to deliver “value” while increasing capacity to better manage larger populations of patients.

    Most of the #2 systems currently available to physicians are on a path to obsolescence because they are too costly and doing little more than either turning doctors into distracted data trolls or force them to force I.T. solutions encouraging the creation of piles of garbage (i.e. cloned/templated information some of which is not valid). Most “integrated systems” are now wasting the most valuable and rarest resource in the system (clinician time and attention) at a time when this sort of cost will be unsustainable as fees for services wane and the patient population increases. Beware, this approach will increasingly prove to be a nightmare for most doctors and patients. Fortunately, there are a few systems that understand the need to manage the necessary structured data via the care team and patient of which the doctor reviews while with the patient. The approaches focusing on letting doctors be doctors are going to deliver wins for everyone.

    If you are a physician, are you doing tasks that you wouldn’t pay someone physician wages to perform? Then why are you doing them, as it is the recipe for disaster as true costs and the value stream to the patient become the keys tor success in the future.

    Ponder on this… Are there risks in texting while driving? How are the risks similar to and different from when physicians are texting while seeing patients? What is the attention cost and risk as to how most physicians are using their EHR? Do patients see value in watching their doctor’s type?

  • Steven Reznick

    Our health system today is the result of years of political infighting and a process where the wealthiest lobbyists ( pharmaceutical companies, insurance companies, plaintiffs attorneys, procedure oriented medical and surgical specialty societies and the corporate world) dictate policy irrespective of the needs of the patient and community and scientific facts.
    As ObamaCare rolls out physicians who went into medicine to help and care for patients will still have that opportunity. Some of these physicians will seize upon the new law to find opportunity in it. Others will bitch and moan. The problem is that the forces in control of the choice of future medical school attendees and the education pathway to licensure and board certification have sold out to a less well rounded physician trained in less time and having less awareness and exposure to the needs of his professional colleagues to care for a patient. This is the real danger of ObamaCare .

  • buzzkillersmith

    Opt out and do cosmetics. We had an ophthalmologist and his family over yesterday. He was visiting the area to learn how to do neck liposuction from a general surgeon so he can get out of doing any cataracts at all, which apparently don’t pay enough for his liking. He mostly does lids now. He’s hoping to built a surgery center to collect the facility fee and on and on. You get the picture. He seemed very stressed and not too happy overall.

    Talking money money money to a family doc who earns much less than half of what he does. As stupid and rude as me talking money to a teacher or a cop.

    Is this man a victim or a perpetrator? I’m not sure, but I am sure that he is well and truly lost as a physician.

    Years ago we got into bed with the businessmen, and now we have their vermin.

    • ProudOkie

      Please don’t take this as offensive – just an observation. I remember in another thread, the MDAs where bemoaning that CRNAs take what amounts to no training for chronic pain management (I don’t know the requirements). Yet a specialty trained opthamologist can take a few courses and become a lipo expert? And earn “nth” more cash than he can in his specialty and “easier”? So does this mean that once you earn a medical degree, you can basically do what you want to the human body, supervise anyone, and set all the rules? Again, sincerely, not trying to be offensive. It is situations like this one that keep me fighting to provide care to 30 patients a day in rural Oklahoma as a Family NP. Yes, my clinic is as independent as they can be in Oklahoma. Very interesting irony.
      BTW, thank you for all you do and for sticking it out and continuing to care for folks. I respect you and admire you and would probably work with you.

      • buzzkillersmith

        No offense at all. I agree with you that it is a sad time when doctors are more focused on business exigencies than we are on taking care of sick people, perverse incentives or no. It’s still sad. Thanks for the kind words and keep up the good work in OK, where I know they could use a lot more docs and a lot more NPs.

      • John Henry

        Well, ProudOkie, in your state and Kentucky, if you are an optometrist, you can basically do whatever you want to the human body without a medical degree, supervise anyone, own a surgery center and pretty much ignore all the rules, except those of the Optometry Board. And it is perfectly legal.

        • ProudOkie

          Just need to clarify so I understand:
          1) As an optometrist you can do ANYTHING to ANY PART of the human body? Please be more specific.
          2) You can supervise ANYONE? Even individuals licensed by the Board of Nursing or Board of Medicine? Please be specific about who “anyone” is.
          3) Own a surgery center that performs what kind of surgeries?
          4) Ignore what rules? Whose rules? What are “all the rules?”
          5) Is the Oklahoma Board of Optometry a valid state board? Was it created by the legislature? Does it have a set of statutes, rules, and clarifications approved by the people of Oklahoma?
          I think when you answer these questions, your “and it is perfectly legal” will make a lot more sense to all readers.
          Thanks for the reponse.

          • John Henry

            1. Yes. 2. Yes. 3. All kinds. Any kind. 4. Only the rules of the Optometry Board apply, not the Board of Medicine or any other board. 5.Yes, so saith the legislature. People-sheeple, who needs their “approval” when you have the approval of the legislature, those who when bought stay bought. You’re welcome.

  • buzzkillersmith

    Oh how wonderful it must be to complain about others who do what you cannot do.

    Perhaps you are unfamiliar with burnout rates among doctors versus other US workers. The 2012 Arch Int Med article by Shanafelt et all might be of interest to you. Maybe not. Cognitive dissonance is hard. Safer to ignore what contradicts cherished, although ignorant, notions.

    In truth, lots of money does not people happy, although we doctors, like most everyone else, are not wise enough to know that. But chronic psychological and physical stress will make people unhappy. And believe or not, we are actually people.

    My suggestion: Go back to college, complete the prereqs, go to medical school (if you have the brains) and then residency, and then come out and show us all how it’s done. That’s called growing up.

  • MarcGarfield_DPM

    My personal insurance has doubled in the last 3 years and covers nothing until I fork out thousands for care. If I drop it and pay the penalty, and would still not have health coverage.

    We have granted cart blanch to the insurance companies that are scalping reimbursements, claim different payer rules for each plan creating mass rejections of payments, randomly unpaid claims that require hours of appeals and resubmissions, They profit egregiously from the new 5010 rule changes causing rejections and will further enjoy the lack of payable claims from ICD10 and 11

    I have EMR rules that require so much work, that I have to see less patients and/or hire more staff to comply or risk the legal definition proper documentation, audits, and recoupments… Tell me again why I should like the “private health insurance business” snugly in bed with government, while doctors cannot unionize, or organize in any manner to oppose the developing oppression… I just don’t understand.

  • flyingrhino

    lets keep things in perspective. it will change medicine in america. not ‘modern medicine’.

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