THE ACA TODAY-4

I contend that the real failure in Obamacare will not be from organizational problems but from the radicalization in the actual delivery of individual care.

Even if the Exchanges finally work the way they are purported to do; providing insurance to a large heterogeneous pool and an average cost that will be lower than the present policies there is no way that Joe Blow is going to get the care he could have received a decade ago.

There is already a national shortage in primary care physicians; family doctors, internists, geriatricians, and pediatricians. The reason of course is due to the fact that reimbursement rates by Medicare and Medicaid as well as private insurance carriers to this group is already below that to specialists.

The problem must become worse with the further loading the system with the large numbers in the Exchange type plans.

The payments proposed for both physicians and hospitals by most carriers who offer “Exchange Plans” are much lower than their present rates. There is only x number of dollars available and the carriers are not in business to lose money.

Since the dollars are lacking the only way to avoid a deficit is to reduce payments to all providers. Many doctors will refuse to participate at that level. Many Hospitals will refuse to sign contracts.

The Insurers are countering by claiming that doctors can maintain their income by seeing more patients; which is difficult in practices that are already overloaded.

One answer to combat this problem is for practices to increase the employment of Physician Assistants, Nurse Practicioners, or Medical Assistants in the practices in addition to RNs or PNs.

There being a great deal of difference in average salary between these groups and what they can do. The lowest level is the Medical Assistant who is most restricted in services rendered.

State Laws have been increasing the duties of the PA and NPs including in some domains the right to write prescriptions and do minor surgery.

The Law now allows Nurse Practitioners to bill Medicare directly at 85% of the fees allowed physicians. Obviously the carriers love that.  If they are in a situation where their work can be countersigned by a doctor; that practice will receive the full physician’s fee.

Disregarding that there are some superb PAs and NPs and some lousy MDs or DOs the degree of training differs greatly therefore the patient is being urged to see a less trained practitioner. Also the patient may not have a choice in the level of the practitioner treating him.

This tract will of course enable a practice to service more patients in a day, but naturally it reduces the time “the physician” will spend with the patient. You the patient have become a commodity.

The appeal to the insurance companies is by limiting services and providers along with the dependency  less highly trained “doctor substitutes” their cost will be materially less.

No longer will rationing of care be limited to “machines” but it will also be accentuated by the scarcity of trained personnel.

The twofold lack of readily availability of services due to lack of personnel and/or the space or equipment for treatment will be tantamount to rationing.

An answer will be the inevitable two tier system similar to the one that arose in Great Britain and in some of the other European nations among them the Netherlands.