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A Paradigm Shift

Brace yourselves. Wear comfortable shoes. Like it or not, you’re about to participate in a paradigm shift in health care. A two-page article tucked into last week’s Journal of the American Medical Association (JAMA) reporting on the results of physician surveys about the Affordable Care Act reflects a genuine paradigm shift.

First, let’s clarify the Affordable Care Act (ACA), currently being wrestled over in the Supreme Court. Despite its legendary length, JAMA cites four key points:

  • It will provide health insurance for the 30 million uninsured Americans. Everyone, no matter what their income, will have access to health insurance that allows them access to care. I should never again have to hear the gut-wrenching sentence, “I’m so sorry. I stopped all my medicines. I lost my job and my health insurance and my family had to eat.”
  • It will standardize health insurance coverage so that the current patchwork mess of variable deductibles, under-insurance, and endless denials of benefits will come to a halt. The concept of “pre-existing conditions” disappears. I will never have to hear about someone being denied insurance because they had back pain a decade earlier.
  • It will improve the quality of care by redesigning the healthcare system so that it financially rewards physicians for providing the best care for patients. It does so by tracking practices using measurable goals (percentage of smokers counseled in smoking cessation, women receiving Pap smears, etc.). This is nothing like the current fee-for-service system, which ignores quality and rewards high volume, such as seeing patients quickly and performing more invasive tests and surgical procedures than needed
  • It will reverse the declining numbers of primary care physicians by boosting their  reimbursement rates while holding steady or reducing the high dollar amounts paid to specialists.

So if this is the ACA, it’s reasonable to ask what doctors think about having the ACA foisted on them. The answer is just as you’d expect. It depends on what group of physicians you ask.

Among those well-established in practice, age 40 and up, a small sampling of 500 physicians showed they generally were split: 44% felt the ACA a was serious step in the wrong direction, 44% felt it was beneficial for all Americans, and 12% were undecided. In a larger sampling of about 5,000 physicians, 58% opposed and 42% supported passage of the ACA. Not surprisingly, primary care physicians were more likely to be in favor than specialists.

Interestingly, although many of the physicians opposed to the ACA itself had numerous complaints about our current system of reimbursement, they’d managed to survive and build successful practices. Their answer seemed to reflect the adage “better the devil you know than the devil you don’t.

But when opposition to anything starts to disappear, change occurs. Younger upstarts question the “wisdom” of their elders and the most vociferous of these elders inevitably get older, retire, and go silent.

And with the power of the young, genuine change occurs
I myself once witnessed a small version of this when I presented to the decidedly older members of an Illinois State Medical Society committee my personal support for the licensing of acupuncture. Their approval was necessary for the state legislature to go forward and create licensing.

Yet despite being presented with good clinical evidence about the benefits of acupuncture, these doctors, all well into their 60s and 70s, were quite hostile, referring to it as “quackupuncture.” It was obvious they’d barely glanced at the clinical material I’d given them. They gave licensing a quick thumbs-down. “More evidence needed,” I was told, clearly a delaying tactic since about 30 acupuncture articles were stacked in front of each of them.

One year later, I was back again and this time there were several new and definitely younger committee members. I was asked to explain some details from the research, and when one member said, “My wife swears by her acupuncturist. I wish there were a few more in my town,” I knew I was witnessing a paradigm shift. At that very meeting the committee voted to approve licensure for traditional Chinese medicine, including acupuncture.

The JAMA piece, short version by age group
A distillation of what the JAMA article reported looks a little different when you separate physician responders for and against the ACA by age:

  • Among practicing physicians 40 and younger, 47% (that’s almost half of all doctors) believe the ACA is a good place to begin, with just 36% opposed to it.
  • Medical students and residents are even more optimistic about the ACA, with 59% in favor of its passage, 15% in favor of repealing it, and 26% undecided. Interestingly, among the 15% who wish it repealed, a full third of this group wants it repealed because it doesn’t go far enough to reform the health care system. These are America’s future doctors and they want all Americans to have equal access to the very health care they’ll be delivering.

A final point of the survey is worth noting. You might think that working in a healthcare system that theoretically could end up as one massive government bureaucracy would discourage even the most dedicated from wanting to be a doctor, but actually just the opposite seems to be the case. After several years of flat application rates to medical schools, with the advent of the ACA the numbers of new applicants have increased by an average of 3% a year.

Additionally, each year has seen an increase in applicants to residencies in the primary care specialties, most notably in family practice, which increased by 21% last year.

So in just two pages, the JAMA article is reporting to all Americans that a paradigm shift in healthcare is underway. And as the author of the survey rather nicely concludes:
The available evidence suggests that the next generation of physicians is ready to take part in this critical venture to define the future of medicine.”

Be well,

David Edelberg, MD

Leave a Comment

  1. KATHARINE says:

    I think the ACA is a very imperfect start. But the heart of the matter is- Everyone deserves healthcare. I hope that someday we will have a single payer system. Perhaps the new doctors are encouraged to think they will be able to retain their altruism as well as professionalism. And we can start focusing on preventative care and proper nutrition. (over 60)

  2. Martina says:

    Dr. Edelberg, my understanding is that under ACA physicians will have limits on what they can treat and what simply they can not. Since the government is in charge reimbursing doctors for treatments, many patients will not get certain care in timely mater (cancer treatment, hip replacement and so on), or will be deemed too old for pacemaker or otherwise. I am afraid that less of premature babies will be saved, and less senior citizens will be allowed to live. Less seriously patients will not get care they deserve, all because the government will ration the amount of money to spent on each patient. Not to mention, that all our health records are linked to HHS already, only to be reviewed and our health care pre-determined. The money for each patient will be rationed. This ACA will shut down private practices, just as my pediatrician said to me, who runs his own practice. As he said to me, we are all going to be working for the government, and my son and my daughter in-law will never pay-off their medical school loans under the government salaries. This particular mandate will not be good. Just ask the Canadiens, as I have asked my co-worker has a family in Canada.

  3. Addie says:

    I agree with Katharine. The Affordable Care Act is just a step in the right direction, nothing more. We can’t go on, morally or economically, with the healthcare system of the past decades. But without a single payer system, the law requires us to support private insurance companies, just as State laws currently require us to support private auto insurers.

  4. Dr E says:

    To Martina
    Bad news. All the fears you describe have been in place for years. Denial of care, restriction of medication, denial of use of emergency rooms, premature discharge from hospitals. And all of this is currently standard operating procedure of private health insurance companies. In addition, reimbursements to doctors over the last ten years (!!) have been either flat or reduced, again courtesy of private health insurers. But bad as the system is, getting health care should be available to everyone.

    • Martina says:

      True. Insurance companies should have never become publicly traded using patients/members as commodities. However, going form a large insurance company to government care will only burden the working class, the tax payers. The money will run out. Medicare and Medicaid are struggling already.
      I would have hoped that health insurance would become a non profit business, serving everyone. Either scenario at this point is not the best solution.

  5. Kate Maver says:

    I work in nonprofit fundraising. It seems that the trend is for every person-centered service to be provided by the nonprofit sector. I guarantee you that this will not work. Really, the government is not the perfect solution, but it is the best solution we’ve got.

  6. Jill says:

    Please post this excellent article to your Facebook page. I want to LIKE it and share it with my fb friends.

  7. Patricia Kothe says:

    That is the most simple and logical explanation of the Afordable Care Act I have seen. Please make sure the Supreme Court sees it before they kill it!

  8. Sara M. says:

    Thanks Dr. Edelberg for summarizing the information about ACA so succinctly. I hope more people can be reached / made aware of the benefits that the American people will realize with it’s (hopeful) implementation.

  9. Mery Krause says:

    Excellent words to promote ACA and it means so much more coming from a fine Dr. as yourself. Wish you could present before the Supreme Court, but then, no one is very young on that bench, are they? I agree with all that you said, but Fox News denies it all.

  10. Susan says:

    I can’t believe my eyes! Let’s see how long it will really take to get into the mainstream medical community.

  11. Ann Raven says:

    Love this! In a couple of generations, we’ll be up there with Germany, Sweden etc.

  12. John says:

    Thanks for the good news! It’s great to hear that doctors are persuaded–especially the younger ones. Now for the Supreme Court!

  13. Addie says:

    Could people please stop lumping Social Security and Medicare together? They are funded and administered differently. Social Security is not in trouble and never has been. Medicare is in trouble.

  14. a.m. says:

    While changes needed to be made, obama pushed through a plan that the majority of Americans disagree with. My daughter has decided against medical school because every doctor she has spoken to has told her ” Don’t do it !” because of obama.Since you are clearly a supporter of obama and his healthcare program, I no longer wish to suscribe to your newsletter .

    • Dr. R says:

      To a.m.
      This blog was created to support dialogue.  As you read through the comments on this and many other articles you will note quite a diverse perspective.  This is good.  It helps people hear other points of view even when they might disagree.  If we engage in dialogue rather than “taking our marbles and walking away”, we demonstrate our willingness to at least listen to one another; something our currently polarized government can’t seem to accomplish.  Please reconsider your decision to unsubscribe: I’d like to continue to hear from you.

  15. The current healthcare model needs to be put on pause. Given the right environment the body heals itself. Alkalinity and oxygenation is key. We are not killing cancer we are killing people. Also most seniors are not dying of natural causes. They are dying of drugs, procedures, and dehydration. This a a travesty!!!

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