Healthcare Reform

Commentary

Commentary on: The Current State of Health

Care Reform: The Physicians’ Burden

Aesthetic Surgery Journal

32(2) 236–237

DOI: 10.1177/1090820X12436839 www.aestheticsurgeryjournal.com

David L. Larson, MD

Downloaded from

The title of the Special Topic paper from Dr. Horton and his coauthors is somewhat deceiving in that, by the time it and my comments reach you, the topic will be “old news.” Talk of health care legislation dominates the media and changes with each passing day. Between Congress, the courts, politi-cal agendas, web logs, traditional and social media, and pundit discussions about exactly what is contained in the 2000-plus-page legislation of President Barack Obama’s Patient Protection and Affordable Health Care Act (also known as “Obamacare”), it is difficult to gain a full under-standing of what will happen to health care in the future. Regardless of the details, though, we can be certain that changes in health care legislation will affect all of us, both professionally and personally, for the remainder of our lives. Decisions made within the next 18 months are as important as any legislation initiated by Congress in our lifetime. It is for this reason that a “noncosmetic” topic such as this is appearing in the pages of Aesthetic Surgery Journal.

The tenets of the Horton et al paper are threefold: (1) The health care system is not “broken” and therefore does not have to be “fixed”; (2) the legal system, as it relates to physicians and malpractice, is “broken”; and (3) the new legislation has potentially negative consequences for phy-sicians and patients. The authors are correct in pointing out that we, as physicians, often treat an inherently unhealthy population of patients making lifestyle deci-sions that frequently result in obesity and its attendant morbidities. In spite of this, health care practitioners are morally obliged to provide the highest-quality care to these patients with “self-induced” morbidities—and we do! In addition, our health care system provides ready access to quality emergency treatment. Research and development of new drugs and technology has been a cornerstone of American medicine for decades and continues in spite of restrictive legislation put in place by the US Food and Drug Administration. It is ironic that, as described in the main article, many of the world’s powerful and wealthy interna-tional citizens from countries such as Canada, Italy, and Japan—with health care systems ranked higher by the World Health Organization than that of the United States— seek medical care here, instead of in their own countries. We must be doing something right!

There is little question that defensive medicine increases the cost of medical care, both directly and indirectly. We are also aware that malpractice legislation at the state level, such as laws recently passed in Texas, can dramati-cally reduce costs of care. It seems intuitive that any simi-lar national legislation would also improve this problem, but the present health care bill fails to do so. One way in which physicians can address the malpractice problem without any legislative action is to institute a disclosure policy within their hospitals. This policy, which has been in place in a number of medical centers and in the Veterans Affairs system for the last few years, involves immediate disclosure to a patient of an adverse event involving him or her. This is almost counterintuitive in our present adversarial culture.1

If the fee-for-service insurance provided through Medicare and third-party payers is to make any economic sense at all, patients must pay for some of the cost of the health care they receive. If they do not, there would be no system of checks and balances on the tests and other pro-cedures that physicians offer. At this point, the Medicare fee-for-service system has no cost sharing at the point of service, other than that which is provided by some form of Medigap insurance, which nearly 90% of Medicare recipi-ents presently have. If the enrollee has little or no addi-tional cost when additional services are rendered, the only way for the provider to earn more is to provide more.

The health care legislation now in place (Obamacare) imposes an upper limit on Medicare spending every year, beginning in 2015. At that time, growth in per capita Medicare spending will be limited to a fixed rate initially set at the midpoint between general inflation in the econ-omy and inflation in the health sector. Then, starting in 2018, it will be set permanently at growth of the per capita gross domestic product plus 1%. As Horton et al note, to

From the Medical College of Wisconsin, Milwaukee, Wisconsin.

Corresponding Author:

Dr. David L. Larson, Medical College of Wisconsin, 8700 Watertown Plank Road, Milwaukee, WI 53226 USA. E-mail: dlarson@mcw.edu

https://academic.oup.com/asj/article-abstract/32/2/236/216642 by guest on 17 November 2018

Larson 237

ensure that this cap is kept in place, Obamacare will utilize an Independent Payment Advisory Board. This board is very limited in terms of what it can implement, since it cannot change the nature of Medicare entitlement itself. The only thing that it can do is cut Medicare payments for those providing services to the beneficiaries. The chief actuary for the Medicare program has warned repeatedly over the past year that Obamacare cuts will drive scores of providers from the program (15% by the end of the dec-ade) simply because payments will be too low to cover their costs.

As noted above, the specter of the Independent Payment Advisory Board–imposed health care controls amounts to rationing—in fact, it has been called the “rationing board” by some.2 Although it is specifically prohibited by law from rationing care, it does have the authority to control prices, and with this power, it will be able to drive Medicare payments so low that doctors will simply stop offering key services to patients. In this way, although Medicare would pay for tests and treatments, patients solely dependent on Medicare would be barred from hav-ing them—which is effectively a rationing of services.

In his recent presidential address to the American Surgical Society, Dr. Donald Trunkey stated that malprac-tice insurance to doctors and hospitals costs 10% of the health care budget. The authors of this article argue that reform of the tort system should be able to reduce that by half. Trunkey suggested that “insurance companies should be allowed to charge different prices according to which

state’s tort laws apply,” thereby allowing patients to reap the benefit of tort reform at a state level, until national reform can be affected.3

In summary, Horton et al have brought important infor-mation to our attention about national legislation that will become much more defined with time by powers beyond our control. Regardless of the content of your practice, there is little question that Obamacare will introduce a change—possibly more like a “burden,” as the title of the paper suggests—to every physician’s practice and way of life as we know it.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

References

1. Boothman RC, Blackwell AC, Campbell DA, Commiskey E, Anderson S. A better approach to medical malpractice claims? The University of Michigan experience. J Health Life Sci L. 2009;2:125-159.

2. Capretta, JC. Paul Ryan's Medicare fix: How to improve health care and shore up the federal budget with one entitlement reform. The National Review. 2011;63:30-33.

3. Trunkey, DD. Health care reform: what went wrong. Ann Surg. 2010;252:1-11.

Downloaded from https://academic.oup.com/asj/article-abstract/32/2/236/216642 by guest on 17 November 2018

Google Sites

Report abuse