How Obamacare will hurt doctors
Medicare expansion isn't painless
By Marc Siegel / NEW YORK DAILY NEWS
Thursday, January 16, 2014, 4:14 AM
A study just published in the prestigious journal Science reveals that new Medicaid patients in Oregon were 40% more likely to use the emergency room than the uninsured were. This finding is not a surprise to me or most physicians — we have known that truth for years.
But it does undermine one of the basic philosophical and practical underpinnings of Obamacare: the notion that expanding insurance will invariably unclog ERs, improve primary and preventive care, prevent diseases and lower costs.
The study underlines the findings of a prior survey by the PricewaterhouseCoopers consulting firm that indicated that Medicaid patients are 35% more likely to use the ER unnecessarily than are the uninsured.
The reason for ER overuse is simple: Medicaid patients (like all insured patients) feel that their insurance card entitles them to health care anytime they want it. When office doctors aren’t available to provide it, they go to the hospital to get it.
But there’s a huge problem with expanding this mentality to ever more Americans, at least given the payment mechanisms in place for Medicaid.
Doctors aren’t available for Medicaid because it pays us poorly while highly restricting tests and treatments, including prescription drugs. Preventive services such as eye care, hearing and dental care are now being limited by most states. A 2013 study in Health Affairs revealed that only 67% of primary care doctors like me, and less than half of all specialists, accept Medicaid.
Even those doctors who do accept Medicaid are reluctant to do so, and many limit the number of Medicaid patients they will see. A 2008 Health Tracking Physician Survey showed that only 40% of physicians accept all Medicaid patients who seek appointments.
Many Medicaid patients who lack a primary-care doctor see the hospital as the place to get all their care. It is not unusual for a Medicaid patient to come to the hospital for a urinary infection, and then ask if they can have their eyes or teeth checked while they are there.
But hospitals, too, are paid less for seeing Medicaid patients, approximately 85 cents on the dollar, and the last thing a hospital needs is a flood of new Medicaid patients rather than patients with private insurance.
I stopped accepting Medicaid insurance 10 years ago. Before that, I was willing to accept a substandard payment out of a sense of loyalty to my patients. I hung in with it for many years.
Ultimately, I found that there weren’t enough specialists willing to play ball with me. It was too difficult to find an orthopedist to treat my patient for a broken bone, or an ophthalmologist to remove a cataract, or even a cardiologist to treat a patient with angina. Plus, the paperwork is prohibitive and the referral networks are narrow.
Everything I know about medicine strongly suggests that Obamacare is about to make all these problems worse.
Keep in mind that our emergency rooms are already overflowing. The number of ERs in the U.S. has declined by more than 10% over the past decade at a time when more are needed. Crowds of patients who don’t really need to be there interfere with the triage and care of sicker patients with heart attacks, strokes, appendicitis, bleeds, etc.
Medicaid is a bankrupt system because of overuse, combined with lack of proper networks. Yet its expansion is at the very heart of the Affordable Care Act.
Nearly 4 million Americans have already signed up for the law’s Medicaid expansion in the 25 states (and Washington D.C.) that have approved it. The remaining 25 states are reluctant to take on the billions of dollars of administrative costs that the federal government won’t cover.
This will have terrible consequences for American health care. Medicaid insulates patients from the real costs of treatment. But it doesn’t insulate doctors from the pain of trying to administer it on the cheap.