AHCA AND YOU #3

Somerset Hospital merges with RWJUH; Hunterdon Medical Center affiliates with the Atlantic Health Systems. The latter differs from a complete merger in that Hunterdon will keep its individual corporate identity and separate medical staff yet all services in both organizations will be commonly available. The Somerville merger will mean that the hospital will be absorbed by RWJUH.

These two actions announced last week is symptomatic of the extreme changes taking place in the health care industry.

I use the term industry advisably since the change from delivery of health care to an industry which began with the advent of the HMO era and the domination of health care by the insurance companies is entering the ultimate stage of commercialization.

The trend of hospital mergers is only part of the process. The days of the Non-profit hospital seems to be in its final existence. For profit commercial hospitals are replacing the traditional non-profit institutions which are in increasing financial difficulty.

This radical restructuring in the Health delivery system is not limited to institutions; the basis of care which  once started in the physician’s  office  has become a dinosaur.   

Not only has the solo doctor’s practice become obsolete in favor of groups; but the groups are in increasing numbers abandoning their independence by becoming units in Hospital controlled mega groups.

  

Is all of this interconnected? The answer is yes. Then the questions are; why, what is the cause, and what is the impact on you the patient.

The why is the simplest to answer; dollars and cents.  Years ago Health Insurance was designed to help pay for the cost of extraordinary medical expenses. 

Medicare and Medicaid determined reimbursement rates for specific but limited elements of society. As Socialism in health care took hold the impact of the HMOs started the revolution which for better or worse is the state of patient care in the second decade of the 21^st Century.

The HMOs (Insurance Companies) not only tied up the people they would service; but determined where they would get care. That included not only the doctors but also the hospitals and institutions that were available to the members of the HMO. Moreover they set “take it or leave it” low fees which often were below Medicare’s. Some carriers even used Medicaid reimbursement which was below economic survival as their base.

The cause is the concept of Socialism which has dominated political philosophy for much of the post WWII Baby Boomers world. There is no denial that the concept is meritorious, but the impact of the application has not been anticipated.  

For Obama care to be practical there has to be a definitive balance between income and expenses.  There are four ways to accomplish this: (1) Increase income by raising (a) insurance premiums, (b) taxation increases ;( 2) lower payouts –reimbursement schedules; (3) limit services; or (4) any combination of the above.

The one element that is politically unacceptable is to raise taxes; so that will be the last resort.

Insurance premiums will be raised since there will be increased demand and usage of services if it does not cost the participant. The insurers are not in the game because they love humanity; profit is the word.

Reimbursement rates are already below market level. This is one of the driving forces that are causing the changes in hospital configuration. Merges are for better cost controls and eliminating reduplicated services. Also it can by sharing assets limit the available resources which are a form of rationing services. Also they will further reduce personnel to bare minimums. All this will compromise quality of care.

Hospitals that do not have a positive merger and whose major patient base is Medicaid or uninsured will not survive ala Muhlenberg.

Once a hospital has been closed the probability of it ever being replaced even in a restricted form is almost nil. The local population base is usually incapable of supporting a non-profit institution. State and/or Federal funding are unlikely since both have dangerously overextended their resources. If the federal government should default on even a portion of its debt there will be runaway inflation.

The time to have sought a commercial for profit corporation to take over the hospital was lost by perhaps deliberate local political inaction and ignoring the at least two that expressed an interest when JFK’s action became apparent.

  

Now-a-days even Physician groups cannot afford the additional expenses imposed upon them by laws. The electronic health records are, contrary to the social pundits, a failure. The systems are expensive to install and maintain (yearly fees). To enter the data in the computer the doctor must either ignore the patient if doing so concurrent with the visit or take extra time afterwards. Different systems do not speak with each other. Much of the data entered by check list is garbage, and has to be repetitive.

One result has been the increased isolation of a physician from the patient and the greater reliance on less well trained Nurse Practitioners and/or Physicians Assistants. Please understand that there are many excellent NPs and PAs but they do not have the broad education exposure that doctors must have. That has to reflect in the level of care. 

Another negative impact on patient care is the fragmentation of care. No longer is there the one on one doctor/patient relationship that persists throughout an illness. There will be different care givers in a hospital from those in the outside world.

With the change in the physician’s role from a self employed or small group partner to an employed member of a large professional unit has also resulted in a marked psychological alteration in the patient/physician relationship.

Gone is the intra-personal intimacy that in my era made the practice of medicine a pleasure. Physicians liked their patients and patients trusted their doctors. Many considered their physician to be a close friend and advisor. The patient was a person not a case number or first name.  The openness that existed impacted on the response to treatment.

The “conversational” office visit that had a positive impact on patient care is no longer possible. There is pressure to accommodate large numbers of patients, so there is a production approach to the visit. Skipping, the first visit paperwork, on a typical visit the initial contact is with an aid who does the routine questioning, and vital signs. Then the doctor comes in reviews the chart, asks a few questions, may check the portion of the body that caused you to seek attention and order more tests or prescribe medication.

This is in part only a fraction of the changes that are going to accelerate in 2014.   

Much of the material I have used for resources comes from the Wall Street Journal which is of course far to right and reactionary. However, there is also  a great deal of commentary in the New York Times; both in its news columns as well as  by slanted op-ed writers. All are worthy of reading. In this Sunday’s (6/23/13) Times on the first page there is an article A Louisville Clinic Races to Adapt to the Health Care Overhaul  with the heading “Remaking Medicine” .It is very informative.

I hope that you have read the first two in this series, and that they have made some sense. I have more planned to follow.