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As the swine flu hype kicks into high gear, and President Obama has instructed the Senate Majority to pass health care reform with 51 votes by invoking a complex procedure called reconciliation which blocks filibusters, consider this: fewer physicians, worsening demographics, and decreased reimbursement are coming to a head as President Obama increases his focus on health care.
After nearly two decades of managed care, the U.S. health care system is about to lurch into a new degree of uncertainty, and the White House seems to be shocked at what has been obvious to physicians and patients for a few years now. The market has reached the point at which it can no longer bear the stresses put on it. So physicians are opting to opt out.
According to The New York Times: "Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president." Further stating the obvious, The Times added: "The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans."
So what have they done? The only thing the can do, limit access to their services and do the best they can with what they've got until they retire and close their offices.
But, the government, the entity that sets the rate on which private insurers base their reimbursement, is trying to balance the U.S. budget on the back of health care. And as The New York Times points out, this is the center of the issue: "Family doctors and internists are pressing Congress for an increase in their Medicare payments. But medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits."
The politicians won't say it. But they know it. A few years ago, a fellow physician who we see on a regular basis was in Austin, Texas at a conference where Medicare representatives were briefing those in the audience on the upcoming changes for the year. When our friend pulled the official aside and asked him when the government was going to stop decreasing reimbursements to physicians who took care of Medicare and Medicaid patients, the official answered him, and we paraphrase, "when you guys close your offices. As long as you're working, we think we can do this as much as we want to."
Meanwhile, the dire reality is starting to creep into the Washington vernacular, and the daily practice of medicine where this scribe still hangs a shingle. Here's what the New York Times wrote: "Some of the proposed solutions, while advancing one of President Obama’s goals, could frustrate others. Increasing the supply of doctors, for example, would increase access to care but could make it more difficult to rein in costs."
In fact, this is an increasingly telling statement of the times: 'Even people with insurance have problems finding doctors. Miriam Harmatz, a lawyer in Miami, said: “My longtime primary care doctor left the practice of medicine five years ago because she could not make ends meet. The same thing happened a year later. Since then, many of the doctors I tried to see would not take my insurance because the payments were so low.”' What the statement doesn't include is the fact that even if insurance payments are low, there are worse problems, such as the fact that some policies don't cover some essential services, such as paying anesthesiologists for sedating patients for stressful procedures such as colonoscopies and pain related injections.
Of course, the usual solutions are being thrown about: "To cope with the growing (physician) shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods."
But those proposals are ignoring the basic problem. There isn't enough money, even at the current rates, to pay for universal health care. And there never will be. It's a good intention, and a noble concept. But it's impossible to bring online without disastrous consequences as there aren't enough doctors, nurse practitioners, or physician's assistants to take care of the hordes of ill Americans whose illnesses are often the results of tobacco, alcohol, and other abusive behaviors brought on by the excesses of the past four decades of "feeling good."
According to The New York Times: "The experience of Massachusetts is instructive. Under a far-reaching 2006 law, the state succeeded in reducing the number of uninsured. But many who gained coverage have been struggling to find primary care doctors, and the average waiting time for routine office visits has increased."
The fact that those that are bright enough and motivated enough to enter the medical field would be insane to take on a six figure debt for their education, on top of the personal sacrifice involved, to come out into private practice as an indentured servant to some corporation or government agency that will then dictate every breath they take or govern their clinical decisions based on rigid practice guidelines.
And here is why the whole thing will cave in: "The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists."
Primary care doctors are overwhelmed. Patients are living longer, and the complexity of their illnesses in increasing, requiring more participation from specialists. If specialists are going to have to care of a larger number of increasingly ill people, they are not going to do it for less.
Conclusion
To be sure, this article is not a call to arms. It's a reality check. The U.S. health care system is up against the wall. The distribution of income to physicians is at the center of the whole thing. And as more time passes, fewer physicians will be available to take care of an aging population with increasingly complex medical problems.
This is a complex issue where concept and reality are so far apart that the line that connects them is asymptotic. On one side the costs of providing top notch care to everyone are prohibitive. On the other side, those in the field of health care who are taking care of those who need it and have access are also being penalized.
The government has decreased physician reimbursement for years. Insurers have piggybacked their own reimbursement cuts on the back of the government's decreases.
And the system is now at the breaking point as fewer physicians can run their practices under the current reimbursement and regulatory systems. We recently received an upcoming reimbursement schedule from a major insurer and saw the following. The newly proposed reimbursement rate for a pathologist's exam of a gross specimen in a surgical setting will be somewhere around $4.
At some point, pathologists won't be looking at gross specimens for patients insured by that third party payer. And clinical decisions based on that, such as chemotherapy, may be delayed, or less than accurate.
What's our point? It's not to whine about the state of affairs, but to provide readers with insight about the state of current affairs, and to allow them to make their own decisions.
From an investment standpoint, as we've noted for some time, the health care sector is a great place to look for short sales. Stay healthy, and be nice to your doctor. He or she may not be in business as long as you need them.
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