Physician’s Message to Obama Care: “We are NOT on board!”

Physician’s Message to Obama Care:  “We are NOT on board!”

 

In a 2012 WSJ article entitled “Obama Care’s Lost Tribe:  Doctors” by Daniel Henninger, the author questions Obama’s deceitful selling tactics of the sweeping overarching healthcare reform law that effectively became law on March 23, 2010.  He goes on to quote Obama during a speaking engagement at the American Medical Association’s annual meeting, “No matter how we reform health care, we will keep this promise:  If you like your doctor, you will be able to keep your doctor. Period.”  This could not be further from the truth. 

Overwhelmingly, physicians are not in support of the bill and are progressively expressing their rebellion. We are not talking about strikes but responding to the upcoming scenario realistically.  It is unrealistic to think that insuring 30+ million more Americans, mainly through the Medicaid program, will lead to greater access or even better quality care.  In other words, healthcare coverage is not the same as receiving healthcare, particularly since physicians are accepting fewer Medicaid patients. It is also unrealistic to think a largely pay-for-performance model, an Obama Care staple, will succeed when so much of the state of medical practice is in the “intuitive stage” of development.    Intuitive medicine, as articulated by Harvard professor Clay Christensen in his book The Innovators Prescription, refers to the impossibility of guaranteeing outcomes. This causes misalignment of incentives to outcomes.  Most of medicine today falls into the category intuitive medicine, such as the specialty Interventional Pain, my area of interest. Other examples are those diseases that can only be addressed experimentally with different outcomes for different patients such as amyotrophic lateral sclerosis, and bipolar disorder.  Intuitive medicine also includes those diseases with no known effective therapies such as multi-drug resistant tuberculosis.  Only in those areas of medicine that are defined as precision medicine can healthcare providers properly guarantee outcome.  Only outcomes that are measurable can be incentivized through a pay for performance plan.  Precision medicine includes those diseases of which the etiologies and therapies are well understood, such as strep throat, Gaucher’s disease, and fractures, a small percentage of overall diseases.  

It’s not that physicians are hateful, opportunistic, greedy or spiteful; they are just realistic in their analysis.  They understand that Obama Care has made it unrealistic and burdensome to provide adequately for their patients.  An environment that embraces misaligned incentives is an environment that ensures failure.  To physicians, this is demoralizing.  Unfortunately, demoralization has a cost.      

On top of the looming physician shortage crisis, minimal attention to malpractice reform, and a constant threat of Medicare payment cuts (via SGR) each year, add Obama care to the mix and you get the physician fast track to rebellion.    Many will be looking to retire early, cut back hours, move out of clinical medicine, or change careers.   To give some perspective, there has been a 7% decline in weekly hours worked by physicians over the last 20 years.  This is equivalent to taking approximately 35,000 additional physicians out of the workforce during a time when the American Academy of Medical Colleges has projected a shortage of 154,000 by 2025.  With near universal coverage provided by Obama Care, the AAMC predicts an even higher deficit reaching close to 200,000 over the next decade.  Furthermore, 24 states and 21 medical societies have projected physician shortages.  Younger physicians (under 45 years) are working even less, averaging 50 hours per week.  These are not good trends and have been found to be directly proportional to physician cuts in reimbursement.  With further threats of reimbursement cuts, one can only deduce that physician hours will decrease further. 

With 835 comments to Mr. Henninger’s article, the most I’ve seen regarding this topic, the physician rebellion is a realistic threat that is garnering an enormous amount of attention.  This means that the water cooler gossip is in full effect amongst physicians and concerned citizens.  Physicians, as the primary directors of U.S. Healthcare, understand that they must be aligned or else failure is inevitable.  Most first year business students understand this simple concept. Unfortunately the Obama administration does not.  Obama Care’s goals are reasonable access and good quality care at the lowest possible cost, but the nation will get the exact opposite: unacceptable access and quality of care with astronomical costs. 

One of the comments to Mr. Henninger’s article may be a harbinger of the physician workforce challenges ahead: “As an attorney whose practice largely involved advising physicians, I sadly now advise young folks who ask me about a medical career: If you're smart enough to become a doctor, you should be smart enough not to become a doctor.”  Jeff Endean-Saginaw, Michigan. 

How can the administration force a partisan “system” upon the citizens of this great nation when those who are responsible for driving the “system” don’t believe in it? Physicians are concerned about the direction of the U.S. Healthcare system.  You should be too.  

 

Article written by:
Robert Moghim, M.D.
CEO, Onyx M.D.



Comments

Jill Sakal

Amen! If ObamaCare is supposed to be great, why do all our politicians get and TAKE! the opportunity to Opt Out?

Kind of like Animal Farm where the pigs set the pace of what is good and what is bad for everyone else but do as they please.

Totally onboard with the article!

Great job!

May 20, 2013, 10:00 AM
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Erik Smith

Bingo, exactly on point

May 20, 2013, 11:49 AM
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Ronnie Duke

+1

May 30, 2013, 10:14 AM
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Paul James Scott, MD

GREAT article. Very well said. Very concerning facts.

May 20, 2013, 5:22 PM
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Shawn Allen, MD

Dr Moghim,

You have nicely outlined some of the challenges that face physisicans these days. Although many of the "Obamacare" reforms are excellent with regards to patients rights with insurance companies the burden does seem to be falling heavily on the physicians . It is true that many of our colleagues are opting out of medicare as it is the low hanging fruit and so it seems that unless they do in fact fix the SGR (which Congress seems to maybe , finally, kind of sort of interested in doing) they will leave no option for physicians but to change professions or sell out to big hospitals as is happening in my community as we speak. Lets hope that others will see the light and realize that you cannot continue to pay physicians less and less as costs go up and up and expect the burden to be on the small practices that strive to continue to provide quality care with a personal touch.

Another final issue to keep an eye on is the fact that they are looking for pay for quality but this is a slippery slope where quality must be defined. Quality in most patients eyes is what will cure their cancer with the highest cure rate . What drug will eliminate their infection with the least side effect, what devices are the safest to use in surgery to reduce pain , hospital stays and infections or revisions. The truth is that quality may become "quantity" in the new definition. So maybe the cheaper option gets higher quality marks but lest call it what it is ... the cheaper version not the highest quality version necessarily. So this may be the next big hurdle to overcome as the focus will be keeping down costs (rightly so) but at whose expense? The patients we care for , that's whose. So when these changes come lets be sure we all look at quality the same way, from the patients perspective first and foremost and not from ours or our governments pocket books!

May 21, 2013, 4:49 PM
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Robert Moghim, M.D.

Dr. Allen, you've hit the nail on the head. The massive formal shift propelled by Obamacare has accelerated the consolidation and vertical integration of providers with facilities, mainly the deeper pocketed hospital systems. This is what you are seeing in your community with physicians becoming employed by larger systems. Since 2000, there has been a 500% increase in employed specialist physicians. This is in addition to the doubling of PCPs in employment models during the same time period. That translates into 25% (from 5%) and 40% (from 20%) of physicians that see patients in hospital settings are now employed specialist and PCP, respectively. Your comment on defining quality is excellent! Defining quality will be an ongoing challenge especially in an industry where medicine is still mostly intuitive. This makes the general basis of "pay for quality" for the entire medical field absurd because it simply cannot be done for every ailment. Only in those areas that Christensen defines as precision medicine, such as Lasix therapy for corrective vision, can you align payment to outcome. The down-stream unintended consequence(s) will most likely lead to rationing of care as the primary driver of controlling costs (as opposed to disease prevention measures) which will ultimately lead to very poor quality healthcare with never ending runaway costs. With U.S debt increases of 61% b/w 2007-2010 and expected Medicare expenditures to rise to 900 billion (66% increase) in just 3 years, no fix to SGR, and looming physician reimbursement cuts openly exposed, all while our nation is turning 65 every 8 seconds... it is no wonder why the physician workforce remains demoralized. There are enormous challenges that require much attention if our nation is, in fact, going to deliver high quality healthcare at respectable costs. However, without true physician alignment and buy-in (the drivers of U.S. Healthcare), the structure and direction that this country is taking to disease prevention, treatment and resolution cannot happen at the highest quality, lowest cost… How could it?

May 22, 2013, 8:50 AM
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Dr. Tod Rubin

All the opinions above are valuable and accurate. Bottom line is the political elite acting in tandem with the Troyka of big insurers, hospital association and big gov't have intentionally excluded the one group of Americans who intimately understands the problems and can offer the most practical solutions. That group is us, the nation's practicing physicians. It's a national tragedy seeing small business owning physicians surrender their practices to hospital systems while at the same time discouraging their kids from considering a career in our noble profession. As mentioned above, the Americans to be most negatively impacted are our patients. Shame on the AMA, our specialty societies and our apathetic, disengaged colleagues for letting this happen with minimal resistance on our part.

May 22, 2013, 4:55 PM
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Robert Moghim, M.D.

Thank you for your comments Dr. Rubin.

The AMA is not a true representation of the physician workforce. In fact, AMA revenue from physician membership dues only accounts for 10% of its 300 million dollars/annual revenue and less than 15% of practicing physicians are AMA members. They had little choice given that they have been granted a government sanctioned monopoly on exclusive billing and licensing codes utilized by the entire industry. A very lucrative arrangement that cannot be ignored. Unfortunately, the public is not aware of that an endorsement by the AMA is truly a misrepresentation. As I mentioned above in the blog, this misrepresentation has consequences. Here are a few... Deloitte in 2013 survey of physicians found that 60% of physicians are looking to retire earlier over the next few years mostly spawned by the passing of ACA, the ACA was supposed to cost $980 Billion but now is reported to have a price tag of $2.7 Trillion (and climbing)- this is at the same time unemployment, if remains at the projected 7.5% through 2014, will = 6 consecutive years of 7.5% unemployment- a first in 70 years, record government debt/deficits with debt reaching & remaining at 70% of GDP (average over last 40 years was 39%). The U.S. fiscal mess will in turn apply downward pressure on physician compensation (as threatened yearly by SGR) due to acceleration of government sponsored healthcare. Today 1/3 of Americans are covered by government financed healthcare but 78 million Americans will be 65 or over by 2030-31 causing a massive expansion of Medicare. Downward pressure on physician compensation and rising practice costs will cause less physician hours worked accelerating the shortage in the physician workforce, causing more disparity between medical specialties- driving more physicians out of primary care... and the multiplier effect of these variables could mean that the foundation that ACA was based upon- quality healthcare at an affordable cost... will not be possible especially if the physician rebellion I explain in the blog becomes reality enough to become a true crisis. I agree that we, as physicians, need to become more engaged than ever before and apply the right pressure in the right areas to ensure we can re-establish the physician/patient relationship. I'm still hopeful but the barriers are ever more complex with the passing of ACA.

May 23, 2013, 8:55 AM
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Doug

What other industry is allowed to dictate and set their own RMR (recurring monthly revenue)? When physicians stop setting follow-up appointments every 2 weeks, 1 month, 3-months, etc. for simple patient maintenance and thus securing their personal income, and patients see a doctor when they need them, more time will be allowed for a physician to see the increased number of patients who, by human nature, are entitled to healthcare. Those on Medicare now should feel blessed to be able to go to a doctor every month for an unneeded "check-up" and allow those individuals who truly need a healthcare visit to receive one. Every other developed nation has healthcare for all except the U.S. Doctors are not overwhelmed; they set their own schedule with 15 and 30 min appointments. When the time slots are filled (with follow-up appointments) there is no more time to see the truly sick...It is up to us as citizens to help take the burden off of an overwhelmed system and see a physician when they are needed.

May 28, 2013, 8:43 AM
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Robert Moghim, M.D.

Doug, I appreciate your comment and respect your opinion but much of what you state is truly just an opinion and has undertones that suggest that physicians, in general, artificially boost patient encounters for mostly financial gains. I can't blame you! Your thoughts are inaccurately shared by the general public and many politicians. The focus on physicians is b/c it amounted to the second highest national healthcare expenditure at 20% with the first being hospital care at 31%. Because physicians direct close to 80% of healthcare cost, its not wonder all the attention. Unfortunately, this is an enormous error and extremely misleading. Healthcare economist Uwe Reinhardt has determined that net take-home pay amounts to only about 10% of overall healthcare spending. By way of example, a 10% cut would amount to only a $24 billion in saving, a drop in the universe when compared to overall U.S. healthcare costs. The real driver of healthcare cost is technology. This was highlighted in a report from the Robert Wood Johnson Foundation. The recommendation to CMS (the intent of the report) was that real health expenditure growth is attributable to medical technology. The reason is that most of medical technology is brought to market without measuring its true effectiveness and eventually gets utilized beyond those patients that most benefit. For example, robotic surgery falls under this category and is now in 36% of all hospitals accounting for roughly 2.5 billion and growing. Even the CBO (Congressional Budget Office) agrees in a 2008 report that stated that technology accounts for 38-65% of new health care spend. Another very important, often overlooked, issue is our nations health. 43 million Americans smoke, 1.3 of U.S. adults fail to meet minimum physical activity, and 60% of U.S kids/adolescents eat more than the recommended saturated fats contributing to our obesity epidemic. Lastly, 50% of healthcare spending is used to treat only 5% of the population. I agree with your statement:

"It is up to us as citizens to help take the burden off of an overwhelmed system and see a physician when they are needed" but your focus is misguided if you think physicians are the main problem.

May 29, 2013, 9:12 PM
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