Republicans and Democrats would both agree the recently passed Patient Protection and Affordable Care Act will expand the role of government. Liberals argued for this increase based in part on their confidence in what they view as success in the federal government’s current involvement. They embrace the argument that Medicare has been able to control costs by using its sheer size to negotiate lower fees with providers. Despite a prolonged debate, this flawed contention largely went unchallenged. There is only one problem with replicating this payment model for virtually everyone: It has not worked as advertised!
Leaving aside the fact Medicare has trillions of dollars in unfunded liabilities and Medicare’s own Office of the Actuary cast doubt on the argument of overall cost savings, the very notion that the government can or will serve as a beacon in a haze of rising health-care costs is prima facie laughable. Yes, the government can bludgeon down fees in certain areas with the payoff being less doctor patient face time and shorter hospital stays. But this kind of reform is not like the mythical Dutch boy saving the day with his finger in the dike.
As a physician, I have witnessed firsthand how the bargaining ability that progressives speak so highly of is not Medicare’s greatest strength, but perhaps its greatest weakness. Medicare pays hospitals and doctors 71 percent and 81 percent respectively of private rates. At first glance, this is primarily the doctor’s problem and not the patient’s. Unfortunately for our country’s infirmed, this is not the case. Ultimately, the brunt of Medicare’s stinginess is passed on to patients in the form of decreased time with providers and compromised quality of care.
In the District of Columbia, President Obama’s back yard, doctors are reimbursed $45.27 for a ten-minute follow-up visit, versus $150.39 by Medicare for a comparable 40-minute visit. One does not need a Harvard MBA to realize that, financially, it behooves doctors to see four established patients in forty minutes as opposed to seeing one returning patient in the same time period. Patients may wonder why doctors spend so little time with them, practically having one foot out the door even before stepping into the exam room. The blame lies in part with Medicare’s reimbursement fee schedule that ironically actually punishes doctors for spending more time with patients. These perverse incentives employed by Medicare carry over to its reimbursement for new patient evaluations as well. The Medicare payment system rewards quantity at the expense of quality.
It should also be noted that Medicare’s physician-reimbursement regimen nationally has not kept up with inflation. This declining reimbursement puts further pressure on doctors to see more and more patients to maintain the same income.
In the years to come, Obamacare will inevitably give the government greater market share in the health-care sector. This will only accelerate the trend toward hospital discharge one day post-surgery and further undercut the patient-doctor relationship.
Patients have reason to worry. Both common sense and the published literature link shorter visits to compromised care. Researchers at UC Davis studied the impact of visit length by recording 294 primary care appointments and found that patient satisfaction increased with length of visit. Multiple studies have corroborated this finding and other research has indicated that patient satisfaction improves outcomes. Research published in the British Medical Journal examined consultation length and discovered that shorter medical visits correlate with the diminished ability of patients to understand and cope with illness. New England Medical Center researchers also discovered that shorter office visits were associated with decreased patient participation in the decision-making process and could be detrimental to quality.
Today’s patients often have multiple complicated comorbidities in addition to their underlying complaints. Physicians simply do not have enough time to adequately address these issues. Doctors naively entered medicine to heal the sick, establish rapport, and advocate for their patients. Perhaps there was such a day when this was possible. Sadly, it is no longer so today. Under Medicare’s stingy and perverse reimbursement system something had to give — and it comes at patient’s peril.
Published in National Review Online: Critical Condition, September 27, 2010.