In last week’s Health Tip we reviewed the groups that have done remarkably well with the passage of the Affordable Care Act (ACA), also called Obamacare. Unfortunately, three of the four big winners are industries enjoying record profits as a result of the new law–the health insurance industry, hospitals (and the physician practices they now control), and Big Pharma.
In terms of the actual patients the ACA is meant to serve, the two winning groups are people who’d been denied health insurance in the past because of a pre-existing medical condition and people living at poverty level or below who are lucky enough to live in a state that accepts federal funding to offset insurance premium costs. Sadly, other people at poverty level are definite losers. There are still four million Americans with annual incomes below $11,000 who are denied access to health insurance because of ideologue governors.
But others are also unhappy with the ACA, and their reasons are perfectly understandable. They’re paying much more money for much less insurance coverage than they previously had.
Loser #1: Self-Employed Healthy People
The biggest losers are self-employed healthy people making too much money ($60,000 and over) to qualify for any government subsidy or tax credit. This group is compelled to purchase coverage they don’t want or need. Pre-Obamacare, they may have had an inexpensive policy that worked for them, but when the ACA passed they received a notice from their insurer announcing that the policy had been cancelled and they had to buy a new one. This group then discovered a landscape of higher premiums, fewer physician choices, and deductibles so high that except for health catastrophes they’d be paying out of pocket for most of their regular healthcare needs.
It’s not uncommon to hear the woes of a healthy self-employed 40-something paying $5,000 a year for health insurance coverage that has a $2,000 deductible. In the past, she may never have spent more than $500 a year on health care (annual physical, Pap test, mammogram). Now that all three are included as a “benefit,” however, but a benefit with a $2,000 deductible, she essentially has no insurance until she develops a serious condition.
“I’d rather pay for my annual physical and Pap smear with my own money and be able to apply the costs to a more reasonable $500 deductible.” I agree 100%. Perfectly reasonable except for one sticking point: the insurance industry’s profits would drop if she were allowed to do this.
Loser #2: Job-Related Health Insurance Holders
Another group likely to experience ACA unhappiness are those who get some health insurance benefits via their jobs. As health insurance premiums rise, many large companies are simply shifting a greater proportion of healthcare costs onto their employees in the form of higher payroll deductions, higher co-pays, and higher deductibles.
Loser #3: Physicians
Physicians themselves make up the third group that expresses a lot of unhappiness with the ACA. Doctors are finding themselves faced with mind-boggling administrative bureaucracy. The Harvard Business Review pointed out that the real growth in health care hiring and training has been in medical administration rather than physicians. The ratio is currently pegged at ten administrators for every physician.
Further, with most medical practices currently using electronic medical records (EMRs), insurance companies can monitor a physician’s “performance.” This monitoring is based not on patient satisfaction, but on the thoroughness of the doctor’s ability to enter data into the EMR. (One reviewer told me I hadn’t been entering “height of patient” often enough.)
Depending on compliance with the EMR system, doctors can be financially punished or rewarded. The ACA term for a doctor’s commitment to cooperate is “meaningful use” under the terms of the Meaningful Use Incentive Program (MUIP). It’s a little hard to explain except by offering a single example (out of thousands).
Let’s say your doctor’s EMR spots that your cholesterol is a bit high. Your physician receives a notification from your insurer about it, followed by a suggestion entitled (unbelievably!) a “medication opportunity” to prescribe a generic (definitely a cheap generic) statin drug. When your next cholesterol test result comes back in the normal range, you and your doctor have achieved “meaningful use” from the electronic medical record system.
Your doctor herself will receive a small financial uptick for her cooperation. She’s using the EMRs in a “meaningful” way. Some physicians tell their insurers to take this idea and shove it.
In my view, not enough physicians are opting out of this insanity. Instead, one of two paths is usually taken:
- Your doctor cooperates 100%, enters all data, and follows all recommendations. She’s rewarded with a modest rise in income.
- Exhausted by endless data entry, your doc simply throws in the towel, sells her practice to a hospital system, and becomes a salaried employee who must follow all the rules of their game. She’s joined an entity called an accountable care organization (ACO). It’s “accountable” in that all the doctors in the group practice “meaningful use” medicine using the group’s EMRs.
The doc is told what to do on all fronts: what specialists she can refer to, what tests or medications she can or cannot order, and what hospital she can admit her patients to (the one that owns the practice, naturally). The administrator can decide whether or not your doctor is a “team player” and if not, may ask her to leave the group. In the process of selling her practice to join the ACO, however, she’s signed a non-compete agreement. This means that when she leaves the group, she has to leave the region and practice elsewhere. If you’ve been seeing at doctor at one of the larger systems like Northwestern and suddenly she’s gone without a trace, she’s not wearing cement boots. She’s moved elsewhere and Northwestern punishes her by not providing any forwarding address.
Personally, I can’t decide if all this is more reminiscent of George Orwell, Franz Kafka, or Monty Python.
WholeHealth Chicago’s experience
Here at WholeHealth Chicago, we’ve seen three trends in the wake of the ACA. We don’t like it that the serious winners are hospitals, health insurance companies, and Big Pharma. We do believe everyone should have access to the health care they choose. For ourselves, we’re neither winners nor losers, as follows:
- We’re happy to be seeing a lot of new patients who previously postponed making appointments because they didn’t have health insurance (“My insurance card arrived and the first thing I did was make an appointment at WholeHealth Chicago.” Believe me, that’s nice to hear!).
- However, we’re also seeing patients unhappy that their insurance covers less than they thought it would. This is a system-wide phenomenon and not limited to WHC. It’s occurring because deductibles are higher than ever.
- Because of these high deductibles, a common patient complaint is that we’re too expensive. In fact not only are our professional fees slightly lower than average for the Chicago region, but we’ve not raised our physician fees since (ready for this?) 2000. I’d bet neither your hair salon nor your pizzeria can say that.
David Edelberg, MD