Obamacare and the Private Practitioner: 2016

Private practice medicine in the United States is rapidly going away.  In the past few years, the percentage of doctors who own their own businesses has plummeted.  The middle class, the supposed beneficiaries of Obamacare, can't afford their deductibles and are avoiding necessary treatments and tests because of costs, leading doctors to have to care for them at more advanced stages of disease.  Doctors (and nurses), the highest trained and most knowledgeable providers of patient care, are mostly data input vehicles for the massive electronic medical records systems.  And the amount of money that has been shoveled into the great abyss of the new government bureaucracy is enough to have bought all of us excellent private care, yet our care and our coverage for that care is worse.

Before Obamacare, the percentage of physicians owning their own businesses was around 70%.  It is now hovering around 30%.  The reason for the shift is not widely reported.  As costs to run their businesses have been going up, reimbursements to doctors are going down, making the margin for being able to stay open smaller and smaller.  Meanwhile, hospitals are doing comparatively better.  Why?  Because they can charge more for a service than doctors can charge.  Hospitals can do this because they have traditionally taken care of the uninsured, and states have written into their books a differential in the reimbursement to make things "fair."  This differential allows hospital corporations the ability to afford to buy doctors' practices.

This affects costs adversely.  (Get ready for a lesson in medical billing "transparency").  As an example, if Dr. Jones charges $535 for a C.T. scan of the sinuses as a private practitioner and submits the bill to an insurer, he may receive as payment $235.  If a hospital owns the practice, and the billing is done through the hospital's auspices, they can charge $895 and may get $695.  If the doctor then looks down your throat through your nose with a fiber-optic endoscope, he charges $180 and receives $60 in payment from the insurers, while the hospital can charge $365 and get $285.

Because of these differentials, the hospital can negotiate with the doctors to buy their medical and surgical practices with the ability to stabilize their drop in take-home income and allow their offices to remain open.  Doctors who used to be staunch advocates of private practice health care have little choice and join "the Borg."  Your costs go up.  Private practice goes away.

(Interestingly, hospital corporations still don't get what they pay for, as doctors often work less diligently as a part of a conglomerate, and even when they do, the costs of running the practices are frequently higher than hospitals predict.  They make up for this by restricting that surgeries be done only at their facilities, as surgeries can make up the profit differential, as anyone who has gotten a surgery bill will attest.)

The middle classes and upper middle classes are bearing the brunt of Obamacare, and it negatively impacts physicians and their ability to care for them.  In order to afford insurance, people often choose very high deductible plans, usually with no health care savings account to assist them with unexpected costs.  And as every American knows, we tend to live right on the edge of what our paychecks allow.  As a result, because it is essentially a cash proposition to go to the doctor until that deductible is met, and since billing for health care is done with the knowledge that most bills are negotiated down by insurers and are inflated as a result, affording a visit to the doctor is financially untenable.  Because we don't have cash stashed away for this contingency, we tend to allow disease to progress farther before it is addressed.

A typical example of the plight of the middle and upper middle class with high insurance deductibles is seen in hospital infusion centers.  When checking in, these groups frequently are counseled that they need to see the financial department to go over their situation.  Americans with a good income may buy a house that is just around the maximum allowed by the banks.  They may choose to send their kid to a private school.  They know that if they work hard, they can eventually pay the bill, because that formula has worked for them in the past.  Then they get cancer.  An $8,000.00 deductible and owing 20% of the bill has them staring bankruptcy right in the face.  This negatively effects care and makes the job of the private practitioner nearly impossible, with "can I do something less expensive?" a chronic refrain.  Many choose no care at all.

Surgeons who used to do frequent semi-elective procedures in communities with relative above average wealth have seen their number of surgery cases plummet, as people will live with their "bum knee" or "sinus" rather than pay to have the problem improved.  (As a result, it would probably not be all that surprising if health care costs are going down, as people are not doing things for their health that used to be commonplace.  After all, a surgeon doing less surgery saves a bunch of money.)

If you have been to a hospital in the past few years, you have probably noticed that nurses and doctors are not in patient's rooms like in the past.  They are camped out at portable computer stations, inputting data so that proper billing is justified.  They are the only people in the system who truly know what care has been delivered and how it should be coded into the electronic medical record system.  From a bureaucratic point of view, this would seem optimal.  Reasonably and practically, however, it is a nightmare.

To adequately fill in all of the checked boxes to justify levels of care for billing purposes would take more time than can reasonably be extended to a patient than the practitioner has available.  Then there is the necessary impersonality of having to look at the computer while talking to the patient so that you don't have to catch up later, making the patient think that you are not listening and are not relatable.  When a patient doesn't trust the doctor, the compliance to the recommended care plan is gone.  That doctor's effectiveness in helping the patient suffers, as does the patient.

The impact of the electronic medical records systems (EMRs) is profound.  Doctors see fewer patients.  They end up bringing more work home.  The resulting notes that are sent to the referring physicians are cumbersome and almost unreadable.  Unless editing is done by some provider with a lot of time on their hands, misdiagnoses are forever listed under "patient problems," as are medications that were never received.  Doctors who spend 45 minutes discussing what another provider might take 5 minutes to do frequently miss out on differential reimbursement because they are not up to speed on the latest coding changes.  Cleaning up a chart to reflect all that had been asked and done could take two or three ancillary assistants that the doctors cannot afford to employ.  Doctors incrementally do less health care for their patients and more data entry facilitation, decreasing the joy and accomplishment of the profession and decreasing the quality of the encounter.

In addition, the whole point of EMR is to data-mine.  The reason for data-mining is essentially to help third parties decide what service that they will pay less for in the next billing cycle.  So by checking the interminable boxes in the medical record, the doctor is complicit in his own financial demise.

The instillation and management of Obamacare is so entrenched now as to be almost unassailable.  It has cost us untold monies.  It promised us much more than it delivered.  It has not been worth the investment.  Yet with the number of people dependent on the government-run elements of covered care, such as Medicare, Medicaid, and Tricare, the possibility of reversing the course back to private care delivery from private hands is about zero.

When the BBC came to America before voting on Obamacare, they sought out people to interview who didn't have health coverage and asked about their concerns.  One woman in Georgia with a strong breast cancer family history was afraid to see the doctor because of cost.  The BBC essentially shamed us for the situation, castigating our system as unfair.  At the time, however, the chance of that uninsured American surviving her breast cancer diagnosis was substantially higher than a corresponding "covered by the National Health Service" woman in England.  No one ever mentioned this fact.

Private practice medicine run by doctors who could "adjust the bill," make payment plans more suitable for indigent patients and create "lost leaders" – taking a financial hit on one service knowing that they could make up for it with the better reimbursement from another service – were a much better means to provide care.  The government-initiated efforts to save us money and increase affordability were dumb from the beginning and have taken away from us one of the greatest things about American health care, namely doctors working with patients to provide care that the doctor and patient both deem is best for that individual.  They have skyrocketed costs and impersonalized care.

Who in his right mind would want to "hang up a shingle" in this environment?

Keith Jackson is a otolaryngology, head, and neck surgeon in Atlanta, Georgia.

Private practice medicine in the United States is rapidly going away.  In the past few years, the percentage of doctors who own their own businesses has plummeted.  The middle class, the supposed beneficiaries of Obamacare, can't afford their deductibles and are avoiding necessary treatments and tests because of costs, leading doctors to have to care for them at more advanced stages of disease.  Doctors (and nurses), the highest trained and most knowledgeable providers of patient care, are mostly data input vehicles for the massive electronic medical records systems.  And the amount of money that has been shoveled into the great abyss of the new government bureaucracy is enough to have bought all of us excellent private care, yet our care and our coverage for that care is worse.

Before Obamacare, the percentage of physicians owning their own businesses was around 70%.  It is now hovering around 30%.  The reason for the shift is not widely reported.  As costs to run their businesses have been going up, reimbursements to doctors are going down, making the margin for being able to stay open smaller and smaller.  Meanwhile, hospitals are doing comparatively better.  Why?  Because they can charge more for a service than doctors can charge.  Hospitals can do this because they have traditionally taken care of the uninsured, and states have written into their books a differential in the reimbursement to make things "fair."  This differential allows hospital corporations the ability to afford to buy doctors' practices.

This affects costs adversely.  (Get ready for a lesson in medical billing "transparency").  As an example, if Dr. Jones charges $535 for a C.T. scan of the sinuses as a private practitioner and submits the bill to an insurer, he may receive as payment $235.  If a hospital owns the practice, and the billing is done through the hospital's auspices, they can charge $895 and may get $695.  If the doctor then looks down your throat through your nose with a fiber-optic endoscope, he charges $180 and receives $60 in payment from the insurers, while the hospital can charge $365 and get $285.

Because of these differentials, the hospital can negotiate with the doctors to buy their medical and surgical practices with the ability to stabilize their drop in take-home income and allow their offices to remain open.  Doctors who used to be staunch advocates of private practice health care have little choice and join "the Borg."  Your costs go up.  Private practice goes away.

(Interestingly, hospital corporations still don't get what they pay for, as doctors often work less diligently as a part of a conglomerate, and even when they do, the costs of running the practices are frequently higher than hospitals predict.  They make up for this by restricting that surgeries be done only at their facilities, as surgeries can make up the profit differential, as anyone who has gotten a surgery bill will attest.)

The middle classes and upper middle classes are bearing the brunt of Obamacare, and it negatively impacts physicians and their ability to care for them.  In order to afford insurance, people often choose very high deductible plans, usually with no health care savings account to assist them with unexpected costs.  And as every American knows, we tend to live right on the edge of what our paychecks allow.  As a result, because it is essentially a cash proposition to go to the doctor until that deductible is met, and since billing for health care is done with the knowledge that most bills are negotiated down by insurers and are inflated as a result, affording a visit to the doctor is financially untenable.  Because we don't have cash stashed away for this contingency, we tend to allow disease to progress farther before it is addressed.

A typical example of the plight of the middle and upper middle class with high insurance deductibles is seen in hospital infusion centers.  When checking in, these groups frequently are counseled that they need to see the financial department to go over their situation.  Americans with a good income may buy a house that is just around the maximum allowed by the banks.  They may choose to send their kid to a private school.  They know that if they work hard, they can eventually pay the bill, because that formula has worked for them in the past.  Then they get cancer.  An $8,000.00 deductible and owing 20% of the bill has them staring bankruptcy right in the face.  This negatively effects care and makes the job of the private practitioner nearly impossible, with "can I do something less expensive?" a chronic refrain.  Many choose no care at all.

Surgeons who used to do frequent semi-elective procedures in communities with relative above average wealth have seen their number of surgery cases plummet, as people will live with their "bum knee" or "sinus" rather than pay to have the problem improved.  (As a result, it would probably not be all that surprising if health care costs are going down, as people are not doing things for their health that used to be commonplace.  After all, a surgeon doing less surgery saves a bunch of money.)

If you have been to a hospital in the past few years, you have probably noticed that nurses and doctors are not in patient's rooms like in the past.  They are camped out at portable computer stations, inputting data so that proper billing is justified.  They are the only people in the system who truly know what care has been delivered and how it should be coded into the electronic medical record system.  From a bureaucratic point of view, this would seem optimal.  Reasonably and practically, however, it is a nightmare.

To adequately fill in all of the checked boxes to justify levels of care for billing purposes would take more time than can reasonably be extended to a patient than the practitioner has available.  Then there is the necessary impersonality of having to look at the computer while talking to the patient so that you don't have to catch up later, making the patient think that you are not listening and are not relatable.  When a patient doesn't trust the doctor, the compliance to the recommended care plan is gone.  That doctor's effectiveness in helping the patient suffers, as does the patient.

The impact of the electronic medical records systems (EMRs) is profound.  Doctors see fewer patients.  They end up bringing more work home.  The resulting notes that are sent to the referring physicians are cumbersome and almost unreadable.  Unless editing is done by some provider with a lot of time on their hands, misdiagnoses are forever listed under "patient problems," as are medications that were never received.  Doctors who spend 45 minutes discussing what another provider might take 5 minutes to do frequently miss out on differential reimbursement because they are not up to speed on the latest coding changes.  Cleaning up a chart to reflect all that had been asked and done could take two or three ancillary assistants that the doctors cannot afford to employ.  Doctors incrementally do less health care for their patients and more data entry facilitation, decreasing the joy and accomplishment of the profession and decreasing the quality of the encounter.

In addition, the whole point of EMR is to data-mine.  The reason for data-mining is essentially to help third parties decide what service that they will pay less for in the next billing cycle.  So by checking the interminable boxes in the medical record, the doctor is complicit in his own financial demise.

The instillation and management of Obamacare is so entrenched now as to be almost unassailable.  It has cost us untold monies.  It promised us much more than it delivered.  It has not been worth the investment.  Yet with the number of people dependent on the government-run elements of covered care, such as Medicare, Medicaid, and Tricare, the possibility of reversing the course back to private care delivery from private hands is about zero.

When the BBC came to America before voting on Obamacare, they sought out people to interview who didn't have health coverage and asked about their concerns.  One woman in Georgia with a strong breast cancer family history was afraid to see the doctor because of cost.  The BBC essentially shamed us for the situation, castigating our system as unfair.  At the time, however, the chance of that uninsured American surviving her breast cancer diagnosis was substantially higher than a corresponding "covered by the National Health Service" woman in England.  No one ever mentioned this fact.

Private practice medicine run by doctors who could "adjust the bill," make payment plans more suitable for indigent patients and create "lost leaders" – taking a financial hit on one service knowing that they could make up for it with the better reimbursement from another service – were a much better means to provide care.  The government-initiated efforts to save us money and increase affordability were dumb from the beginning and have taken away from us one of the greatest things about American health care, namely doctors working with patients to provide care that the doctor and patient both deem is best for that individual.  They have skyrocketed costs and impersonalized care.

Who in his right mind would want to "hang up a shingle" in this environment?

Keith Jackson is a otolaryngology, head, and neck surgeon in Atlanta, Georgia.