The Future of Medical Specialists under the Affordable Care Act

ObamaCare has as its modus operandi a focus on medical management by already  beleaguered primary care physicians and para-health professionals, at the expense of medical and surgical specialists.  The law's administrators hope to control costs by cutting already bare-bones specialty physician payments, limiting medical technology and access to imaging, and instituting de facto health care rationing.

Medicine has been increasingly high-tech and more specialist-oriented, resulting in better, albeit more expensive, care.  To cut expenses, ObamaCare is naïvely turning to an outmoded model of health care delivery -- one that has been shown to have comparatively poor patient outcomes.

Primary care physicians were forced during the recent dramatic growth of HMOs to practice less general medicine and essentially become gatekeepers for patient access to specialty care physicians.  Because of this, and the increasing threat of lawsuits for missed diagnoses and rising patient expectations regarding disease outcomes, specialty referrals have risen dramatically.

Specialty care gives better outcomes for multiple disease processes, but it has contributed to the expansion of the use of technology in diagnosis and treatment.  This is part of the reason for cost increases far outpacing inflation, and leads us to understand why there is increasing cost in modern medical care.

Turning into gatekeepers at the expense of actually practicing medicine has decreased the overall diagnostic and treatment skills of primary care doctors.  Plus there is just too much to know regarding every medical issue in every specialty to avoid delaying care for potentially litigious patients.  Add to this the 30 million extra uninsured, the dramatic growth in the elderly population, and the projected 65,000-doctor shortage a decade from now, and the responsibility foisted upon the primary care doctors is overwhelming.

Too many patients, too little time to accurately diagnose, and too little knowledge of current advances in treatment with dwindling resources available to help, will make practicing primary care medicine impossibly difficult.  Unconscionable waits will go hand in hand with scandalous outcomes, just like they do everywhere national health care takeovers have occurred.

Specialists, projected to be in similar short supply during the same time period, will still be here.  But a roughly 50% cut in reimbursement by the Medical Payment Advisory Board, adjusted for inflation in the next ten years, will result in doctors closing their small business-structured practices and folding themselves into hospital-owned models.  They will be the doctors most impacted by the negative consequences of the ACA, as they will become employees, subject to bureaucratic goals in patient care, and will be restricted in testing and treating patients.

Hospitals, the bosses of the specialty physicians, will be given a limited amount of money to treat a patient who has a certain diagnosis code.  For instance, someone might be admitted for the diagnosis of pneumonia, and the IPAB will allocate corresponding funds for payment.  Pretty soon, it will become very apparent that expensive imaging and bronchoscopies will drain that money, and therefore profit, away from the hospital.  Specialists will be told to cut back.

Specialists will have to work within the hospital bureaucracy.  They will be told that they are not dealing with "Mrs. Jones."  They will be treating patient 67, diagnosis code 675.3, with protocol B-4, modified by cost-containment option 201, with estimated cessation date 4 days from now, subject to penalty.  That is because they are no longer treating a patient.  They are a cog in a bureaucratic goal-related, impersonal, number-crunching exercise.

Hospitals will also be penalized if patients are treated in the hospital for a diagnosis code, are discharged, and then bounce back to the hospital, sick again with the same illness.  No further payment will be allocated.  This will result, indirectly but very predictably, in the sickest, least compliant patients going to "dumping ground" hospitals.  This may also necessarily be the final destination of the most talented specialists as well, as costs will have to be "modified" to conform with the ACA in this group of patients.

There are many great specialists in countries where national health care delivery is in place.  But actually getting to them is hard -- much harder than in the U.S.  And having an American-like experience with the doctor evaluating, treating, and managing the care of you and your illness is not common.  Getting treatment in a timely fashion is harder yet.  But the ACA doesn't foresee this as something Americans will protest, apparently.

All in all, using the obsolete notion of reverting to primary care-managed health care delivery and wishing away expensive specialists will lead to ever-worsening health care outcomes.  Not paying for technology and specialty testing and procedures will stop advances in medical care and increase the morbidity and mortality of illness.  Cynically, the cost to society in lost work production may be balanced by the early deaths of the sick and elderly.  Maybe this is the ultimate, unspoken means of cost containment that they haven't told us about.