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Health Care Reform: The Worst is Yet to Come

Do you see or do you observe? Most readers have likely given just a glancing glimpse of the photograph to the left, which I took during recent vacation in Costa Rica. Most, including me, would have recognized that the photograph is a tree, and then moved onto the riveting text. While this identification would be correct, it would not be the whole story. Look more carefully, and see if you overlooked a finding on the photo during your cursory review of it.

The health care reform plan, now law, also has many camouflaged elements that were not visible, even to the informed public. In the coming years, as the layers are peeled back, there will be many surprises for the public and for the medical profession, which I hope and pray will remain a profession.

The Patient Protection and Affordable Care Act was signed into law in March 2010. No, it won’t be repealed, despite some shrill populist campaigning to do so from the political right. I also doubt that the judiciary will turn it back, despite efforts to do so in nearly 2 dozen states. Nevertheless, public support of the bill will steadily wane as its provisions and costs become apparent in the coming years. It remains my view that the plan will cost much more than predicted, and will deliver much less than we have been promised. When this inevitable result occurs, the nation will collectively develop acute carpal tunnel syndrome from the wild finger pointing we will all be engaged in.

Here are some highlights of coming attractions.

No permanent SGR reform. Congress is still kicking the can down the road, year after year. Let me use a fancy gastro term to describe this phenomenon – no guts.

A ‘physician compare’ website will provide the public with results from the government’s Physician Quality Reporting Initiative (PQRI) ‘quality’ measurement program, which we practicing physicians deride as a sham that wastes time and money and fails to assess true medical quality. I’d like to think that I practice high quality medicine. Unfortunately for me, none of the things that I hopefully do well can be measured. What is easy to measure, however, doesn’t really matter.

Mandatory deductions in Medicare reimbursements will begin in 2015 to physicians who do not submit acceptable PQRI data to the government. Physicians must participate in this bogus program, or we will be docked. Another fine example of your overtaxed dollars hard at work.

Requires that an imaging service (e.g. CAT scans or MRIs) with physician ownership advise patients that the imaging services can be obtained elsewhere and provide them with a written list of other available imaging centers. This latter provision is bizarre. Would we expect any business to provide the customer or client with a written reference list of competitors? When I stop by Starbucks for some overpriced and bitter coffee, I don’t expect them to hand me a list of other coffee bars down the street. Perhaps, my own gastroenterology (GI) practice should prominently list all other GI practices within 5 miles of our office in our waiting room.

Seniors currently enrolled in Medicare Advantage programs (25% of all Medicare participants) are about to be cut loose when the government cuts payments to these private programs. Of course, benefits to these seniors will be cut accordingly. Many will be forced over to traditional Medicare at higher costs because of high Medigap policy costs.

Allots relative pocket change to examine alternatives to current medical malpractice litigation. In other words, we are going to study the problem. While we’re at it, let’s commission another study to confirm that the earth is a sphere and not a flat plain.

Independent Payment Advisory Board is a 15 member cabal that will wield great power to control Medicare costs. They are prohibited from reducing member benefits, rationing care, increasing premiums or raising taxes. So docs, what is the one remaining pool of cash that these guys have access to? See photo below.

Of course, I could write, “Wait, there’s more!”, but you get the idea. Thirty-two million citizens are to be given medical coverage, half of of these under the strained and sagging Medicaid program, when we don't have sufficient primary care power to meet current needs.  Who will see these patients?  Can physicians afford to incorporate large volumes of Medicaid patients into our practices?

I acknowledge that many supporters of the health care reform legislation truly believe that it will serve the public good, or at least initiate a process that will ultimately deliver true reform.  I don't agree with them.  While there will be fewer uninsured Americans - a most worthy outcome - it is not clear that they will have ready access to quality medical care. Is it worth lowering the quality of our medical care system in order to cover more individuals?  Many would privately agree with this compromise, but would never say so in front of a microphone.
While it is politically palatable to confiscate and redistribute physicians' incomes, imagine the tsunami that will develop when the patients are fleeced and controlled.  The truth is, similar to the taxes paid by the wealthy, that even if all physicians' incomes were appropriated, it would do nothing to address the cost escalation spiral.  Who will tell patients the truth that the era of endless medical care and treatment will be euthanized?  Look what happened when the apolitical USPSTF issued some modifications on mammography guidelines.  Does the public really believe that they will be left whole afterwards?  Once the medical profession, Pharma, insurance companies, et al are dumped into the wood chipper, then the public will be targeted.  Physicians are the low hanging fruit, but be assured that your government will reach the top of the tree.

I feel like we are all stumbling through the rain forest, during a downpour with crackling lightning overhead. We can’t see where we are going, and we can no longer find our way back to where we began the journey. The ground is slippery and we reach for a branch to steady ourselves. Of course, we didn’t see the viper wrapped around the branch, although he found us. The most dangerous predators are those we cannot see, the lurking in the shadows, ready to strike even though our government guide has assured us that it is safe to pass.


  1. You state that public support for the Affordable Care Act will wane. In reality, public support for the act is increasing. Do you have an estimated date at which time public support will start to drop? Did you know that public support is increasing?

    I did a quick Google search on "public support Affordable Care Act" and found, for example, this:

    By a 15-point margin, Americans express a favorable view of the new health reform law – 50% to 35% (down from 41% unfavorable in June).

    By an 8-point margin, 43% of Americans believe that the country as a whole will be better off under the new law, while 35% believe that the country will be worse off.

    Support among seniors is also growing:

    The percentage of seniors who held an unfavorable view of the bill has decreased – from 56% to 46% (from April to July).

    The gap between seniors who have a favorable vs. an unfavorable view of the bill has narrowed to 8%.

    The poll also found only 27% of Americans support repeal.

    You can find the figures here:

    I'm interested in the polls you apparently know, in which the public is turning against the Act. Could you provide a link?

  2. Wow! Excellent post and fine rant. I have nothing to critique and defer to the hoards of angry statists about to descend upon you.

    Well, one critique, I guess. When I walk into the Starbucks to buy a cup of bitter, overpriced coffee, they have the prices posted up on the wall for all to see. When I'm sent to the hospital for a CT scan, I have no idea what I'm being charged until I get the EOBs from my insurance company.

    I do think the medical profession is about as opaque in their pricing as you can get. And I say this as a fellow medical professional.

  3. @LG, thanks fopr your comment. There is a poll out there for everyone. Here are two for your review.

    @AB, what is your profession?

  4. Why, I'm just a mindless scope jockey.

    @ LeisureGuy: I look forward to hearing Democrats running for (re)election vigorously proclaiming their support for Obamacare this fall. The deafening silence so far is undoubtedly because they are not reading the correct public opinion polls and are under the mistaken impression that people hate that monstrosity of a bill.

  5. I agree with part of your post - that there will be many disappointments as the US tries to join the rest of the civilized world in health care.

    I was just rejected for the new PCIP (pre-existing condition insurance program), because.... wait for it, I value health insurance enough to be currently (over)paiding for partial insurance. If I had rejected the offered plans with exclusions I would be able to get PCIP.

    So now people like me consider "medical-roulette" - go six months totally uninsured in the hopes that the PCIP will exist and be accepting future enrollment.

    And the other kicker - the PCIP would cost me twice what I could get through for a comparable plan, if I had an unblemished medical history.

    With exclusions and a ten thousand dollar yearly deductible, I pay about 60 percent of the PCIP rate, (which has a 2500 deductable).

    People worry about the PCIP funding running out. But I find it hard to believe that someone unwilling to pay for partial catastrophic insurance will be able to pay almost twice as much for the PCIP.

  6. One of the few bright points of the health care reform law, is to eliminate the pre-existing medical condition exclusion. This was wrong and I hope it will soon become extinct.

  7. Thank you for your comment. I'm glad we agree on that point. But if this first crack at PCIP is any indication, we "underwriter's playthings" will have a long wait.

    I could have accepted the notion that only the totally un-insurable would be covered by this initial program. But to cover the "partially-insurable" only if they rejected that partial insurance, seems pretty incompetent (or evil) to me.

  8. Doc, don't you understand why you didn't get your universal caps yet? Or are you being deliberately obtuse?

    Why spend the money and political capital on something that (a) doesn't work (b) the feds can't address anyway because they're state law claims (remember federalism principles?) (c) has Constitutional implications (remember the 7th Amendment?) and (d) will be unnecessary under single payer?

  9. Last Anon..

    Didn't you hear? Doctors are above the Constitution and especially the right to a civil jury trial (7th Amendment). They need "special" tribunals to hear their cases. Complex contractual disputes, intellectual property cases and products liability cases are good enough to be heard by a jury of citizens, but holier than Jesus, Allah, and Krishna doctors need that special system to hear their claims.

    The Constitution is for the birds and the simpletons.

  10. I post my common physician office visit fees and immunization fees on my website, at my new patient form station, and in each patient room. My fees are only 5-10% above my best PPO insurance contract, compared to most offices that charge 200-400% over what insurance companies actually pay.

  11. Comment on a different matter:

    I just listened to all your podcasts and they're informative. Please keep it up because things like that help patients like me.

    However, and this applies to a lot of podcasts, you're hard to hear. I really had to crank the volume. Having worked in media, I know there's usually one simple fix for issues like this - "get closer to the microphone!"

    I look forward to continuing to enjoy any podcast you put out (...that includes slightly disagreeing with some of the content).

    Thank you.

  12. I thank the above commenter for listening to the podcasts. As you astutely observed, I am hardly a professional broadcaster. I have always had a rather quiet voice, but will try to ramp it up the next time I am 'on mic'. I have learned that speaking for a few minutes as a monologue is tougher than it looks. I have developed a high level of respect for folks who do this for a living.

  13. Don't get me wrong; I'm not expecting a professional and/or perfection. Just having any doctor speak out like this is wonderful!

    At the risk of sounding too bold, can I also suggest that when you do make a podcast, at the same time add a blog entry heading announcing it? The entry does not even have to include any written text but can serve as a place for listeners to ask questions or comment on the podcast. For instance, when I listened to the episode touching upon caps on malpractice settlements my mind jumped to all my favorite vermin doctors getting away with a lot. My question would be: Am I off base?

    P.S.: A tweet on Twitter [Hmm!] is a good place to announce a new podcast episode, thereby helping to drag folks over to your blog to listen and comment.

  14. Great ideas! The podcasts are supposed to be announced on my twitter account. If you feel the urge to comment on a podcast, there is likely a post on Whistlelblower of a similar theme where you can rant.

    To all: here's a link from Politico on the popularity of the health care situation.

  15. As someone who is on Medicaid (waiver) I will share my opinion. Not that anyone cares...

    I have Multiple Sclerosis. I HATE Medicaid.

    For one thing, doctors don't take Medicaid. They don't. Those of you who are for this "great" don't get it. Doctors do not have to accept you as a patient.

    As soon as I showed my neurologist my Medicaid card I was asked to leave the office. She decided on the spot not to accept Medicaid. And yes she has the right to refuse to accept Medicaid. It is her practice.

    I am sick and tired of losing my doctors. I lost my Urologist. I lost my opthamologist. (optic neuritis is an issue) After awhile you give up and think perhaps you are in a short line to get off the planet as quickly as possible. They accept Medicare, but not Medicaid.

    That is my experience since transitioning from BC/BS to Medicare to Medicaid in two years... which happened only because my husband became my EX.

    The standard of care (or rather the difficulty in OBTAINING care) has gone down quite a bit since I went on Medicaid.

    I prefer private insurance. At least I could find a doctor.

    And as for the picture of the tree- here's what I say: for those of us on Medicaid, it scars us for life.

  16. This comment has been removed by a blog administrator.

  17. As you have said correctly. More of the viewers are interested in watching the movies instead of the content.

  18. I am simply a long suffering Radiologist who has seen many iterations of regulatory phenomena come and go. MQSA (introduced by Bush sr.) was a classic example of regulatory fiasco (in my opinion) by attempting to regulate a radiologic exam which has a generally low accuracy rate (85-90%) by radiologic standards. Some criteria which were frankly scientifically "fishy" such as film"overprocessing" for example have been made technologically obsolete by digital radiology. I have honestly seen FDA and state accreditation inspectors issue violations without properly performing their investigatory duties.This appeared to be due to a generally small number of verifiably noncompliant sites. This convinced me to abandon the modality.I referred my patients to other very good local practices and we all survived just fine. Generally the tasks of oversight become overwhelming to those to whom they are charged. For example,UHC claimed 2-3 years ago that no facility without appropriate accreditation would be allowed to participate in their (under-reimbursing) network. Deadlines were given and moved. I have not seen any evidence of local facilities being dropped;mainly because one can almost continuously be "in process",for example. In the end it comes down to how much one feels like putting up with this nonsense vs. pursuing other avenues available in life. Thanks for the blog. I have always appreciated my gastroenterologist.

  19. "One of the few bright points of the health care reform law, is to eliminate the pre-existing medical condition exclusion."

    I'm not so sure the insurance companies have heard the news.

    I'd be interest if your patients are receiving insurer calls asking them if they have any questions, and then the fefnicute rep alters the conversation into information gathering.

    I'm unsure if it is an attempt to financially rate patients -possibly for an bailout accounting?- but I think it oddly iterant.

    BTW, this process of inquiry was repetend in a person who had cancelled one plan in favor of another


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