Monday, July 2, 2012


I have always like many of my peers believed that it was Society’s obligation and responsibility to see that no one for any reason should be denied access to treatment. The question being how that should best be accomplished.

The eliminating the broader Medicaid eligibility will of course defeat one of the goals of increasing the overall population coverage. Moreover none of the law deals with the “illegals” who are morally entitled to the same care afforded others.

One of the most difficult problems I have today is to analyze the American 21st Century version of health care as it is related to a combination of availability, quality, and effectiveness.

My perceptions are clouded by my own experiences in what I considered the golden era of American Medicine. This was a time when it was far superior to that of any other country. The only negative was availability to all living within the county’s borders.

Throughout the years up to the 60s charitable donations helped maintain free hospital clinics which were staffed by attending physicians as part of their hospital responsibility along with “ward” services in exchange for their right of privileges to treat their private patient. At least in the North East where the tradition started it worked well.

The breakdown of this system began with the advent of Medicaid. Once again a well intentioned concept initiated a reaction that led to unforeseen results.

Money is the root of all evil. The hospitals found out that they could be reimbursed for treating the economic poor who were Medicaid legible. Not only the facility use but the professional services were also compensated. Someone would get the money.

With the advent of the HMOs; compensation was extended to the insured. However, the HMOs negotiated contracts directly with the hospitals often with payments below the going rate. Here too often included in the hospital contracts were fees for physician’s care.

However instead of compensating the physicians that were providing the services, hospitals pocketed that portion of the bundled reimbursement sums received. This led to doctors refusing to staff the so called charitable services. Hospitals began employing physicians to provide care in the clinics and in house. They were now providing professional services and making a profit.

Medicare created another level of Government input into the delivery of health care. One no longer dealt with doctors, nurses and therapists; instead they had become “Providers” who were paid for their services on a scale determined by the government or insurance company?

The delivery of care had become a business attracting entrepreneurs. Protocols were being developed by financial wizards to determine payment scales for various services and "appropriate" hospital stays. The bottom line not the patient’s welfare or the value of the“provider’s” care was the driving factor.

Increased regulations and/or insurance carriers’ requirements to be met for reimbursement plus the pressures of our litigious society has drastically increased the costs of operating a practice; forcing doctors to combine in groups and delegating much of the patient care to PAs and Nurse Practitioners.

We now have a population who has accepted the concept of a structured medical office in lieu of a personal physician’s practice. Their contact with the doctor is probably the least time consuming in the visit.

What changes will the mandated insurance laws bring? That all depends on the dollars that are available. If funds are insufficient for the increased numbers absorbed into the system there will have to be reductions in either or both professional reimbursement and allocation of services; diagnostic and therapeutic.

With decreased professional reimbursement there will be an exodus of highly trained individuals from the field. This is a trend that is already in progress and may be exacerbated.

At the same time health care will not be attractive to the highest level college graduates. This will result in an increase reliance on lesser trained individuals who may be adequate in the routine aspects but will also be more dependent perhaps by regulations of cookbook medicine.

There are two old adages “You get what you pay for” and “You get nothing for nothing” which will be applicable to the quantity and quality of health care the individual will receive.

Under any circumstances there will be only a finite amount of dollars available. The net results will include an allocation of tests and procedure. The latter may result in either delays or denials.

There may also be limitations in choice of physicians to either a panel member or one willing to accept a low fee. The expertise of the doctor will not be a consideration.

At the same time the provider be it a physician, chiropractor, or therapist will be impacted by the limited funds by having the reimbursement for services lowered from present levels.

Over the past few years Medicare and Medicaid payments which are lower than usual and customary fees did `not increased in line with the “Cost of Living” ratio. This of course means that in buying dollars these individuals are receiving less each year for their work. `Of course the third party payers have taken advantage of government fixed rates.

This trend will continue if money is tight. It will impact on patient care with further modification of the production line less on hands business practices to a point that as a result of increased volume many will not see a doctor at any point in the office visit.

There is another aspect that is being ignored but may result in a complete change in our way of life and personal liberty.

There is an ongoing tendency by legislatures to mandate that doctors either accept or treat all patients under the government pay scales which can be cut at any time or be fined. If that becomes a law they may even be prosecuted as criminals if they fail to do so.

Physicians do not have the right of unionization except where they are employees. The AMA is not a union and when any cohesive action has been attempted in the past the Society and its individuals have been threatened with restriction of trade suites by the government.

One professional segment of society is being threatened to be treated as if we lived in a totalitarian state. Once the principle of restricting civil liberty rights is applied to one group the logical step will be to gradually extend it to all society. The distinction between Socialism and Fascism is nebulous.

I know that I am presenting a disturbing dark picture but I believe that it is within the realm of probability.

I started out by saying that “it was Society’s obligation and responsibility to see that no one for any reason should be denied access to treatment”. I will modify it by adding that it is not society’s obligation to make everyone accept that access.

Let us hope that our continued venture into socialism does not end in disaster. ``

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