Earlier this week Gov. Rick Perry sent a letter to US Health and Human Services Secretary Kathleen Sebelius and stated that Texas is opposed to the expansion of Medicaid as provided in the Patient Protection and Affordable Care Act and to creating a state insurance exchange. This announcement came on the heels of the Supreme Court’s decision to uphold the PPACA.
Both decisions affect Texans as many Texans depending on government-funded health insurance face a crisis in access to health care. The problem is that having coverage is not the same as having access, and access to a waiting list is not access to health care. Handcuffed by stifling regulations and money-losing reimbursement levels, an accelerating number of physicians have stopped accepting new patients who have government-funded health insurance — Medicaid and Medicare. Only 31 percent of Texas physicians accept new Medicaid patients. The negative trajectory of this number is just as alarming, having been 42 percent in 2010. In Dallas County the numbers for 2012 are even more bleak — just 24 percent of physicians accept new Medicaid patients. At this rate you have to wonder when the acceptance rate for our county will fall into the teens, or if we will actually see single digits. Since 2010, the percentage of Texas physicians accepting new Medicare patients fell from 66 percent to 58 percent. In regard to dual-eligible (Medicare-Medicaid) patients, 40 percent of physicians statewide and 32 percent in Dallas County accept them. Coupled with the potential negative impact of the Medicaid 1115 Waiver on hospital reimbursement for low-income patients, we could be facing a devastating perfect storm of decreasing patient access.
This is why the proposed expansion in Texas of the Medicaid program under the PPACA by itself is not the answer for uninsured and low-income patients. Why expand coverage in an insurance plan that has shockingly limited and unacceptable access to care? This simply gives false hope to the 25 percent of our fellow citizens who are uninsured that their participation in the Medicaid program will dramatically improve their ability to access the healthcare system. We need a plan that expands coverage and access to care.
The gold standard for this access must embody timely access to quality, cost-effective care. A key ingredient of this expansion of access is the streamlining of the oppressive and progressively costly regulatory process so we physicians can devote more of our time to caring for patients and less to caring for paperwork. Paperwork never healed anyone. Improving patient access to health care also must involve increasing physician reimbursement to viable levels where we do not face the prospect of paying out of our pockets for every Medicaid patient we see. By working with our legislators and congressional representatives, we physicians can have a significant impact in improving access to the healthcare system for the uninsured of our state. We physicians must be forceful advocates for our patients. However, we should not put the cart before the horse. Instead of initially expanding coverage to the uninsured of our state to an overly flawed and ineffective insurance system, we should first concentrate our efforts on improving actual access to care through the Medicaid plan we currently have in place. Let’s get to work.
Richard W. Snyder II, MD
Dallas County Medical Society
I bolded the statements that I feel are particularly overlooked in the whole Obama Care kerfuffle. For more physician opinions on PPACA, including my own, see my Obama Care tag.
HI! With the heart of Obama’s health care reform ruled as constitutional just now, I was curious how you think this will affect doctors?
Oh joy a question about politics I cannot contain my excitement.
(Nothing personal! I just hate politics. So this reply will be short.)
First, let’s get the term straight: The Affordable Care Act (aka Obama Care) is not healthcare reform, it’s healthcare insurance reform. And you can (attempt to) fix the insurance system all you want, but until you fix the healthcare system itself, costs will continue to skyrocket and reimbursement will not be able to keep up.
Second: read this prior post where I discuss my main objections to the ACA, plus what I think would really need to change in the US healthcare system for actual healthcare reform.
Lastly: read the reblogged posts under my Obama Care tag, particularly the excellent posts by WayfaringMD and Jay Parkinson, for more MD perspectives on the issue.
about-hortense replied to your post: Great, lots more people are about to have insurance.i don’t understand the meaning of that BUT. This topic intrigues me a lot and, as a non-american, I’d like you to stretch out ya point of view which, obviosuly, lingers behind that opening adversative.
What I was referring to is that there’s a huge deficit of primary care doctors in this country, and our system does not do a very good job of encouraging trainees to go into primary care.
Putting it simplistically, billing in the American medical system is based on procedures, tests, and the complexity of diagnoses. Doctors bill a certain amount for different things, and insurance companies generally pay a higher percentage of what doctors charge than government programs like Medicare and Medicaid pay. So the more patients you have with private insurance, the better your reimbursement rates.
The problem is that things like preventive care and regular follow-ups for chronic conditions (things which should theoretically save the system money by preventing conditions that require expensive procedures and tests) are not considered complex enough to warrant decent pay from government payor sources (Medicare/Medicaid). And guess what takes up the majority of primary care docs time? You guessed it, preventive care and follow up visits.
I’ll post a little more about my thoughts on the ACA later (only because a reader directly asked me to comment on it, sigh — Cranquis hate politics, Cranquis smash), but this post pretty much sums up my feelings on it already.
Aloha, Ben Dover! I am so glad that I have already posted my thoughts on Obama-care in a couple of prior posts, so that I don’t have to spend time dwelling on this political stuff again. Check those posts out… hopefully they will answer your question. :)
(It’s not that I don’t like answering questions, Ben — I just get so frustrated with politics that it chafes my chaps to write about it.)
Ok, first of all — where is that money for EMR supposed to come from? That’s right: my taxes. Where will a greater proportion of the tax money come from? Hmm, well, who pays higher taxes: the patients who don’t have health insurance, or the doctors? Hmm…
But yes, in some magical world where real-life in-practice doctors could design an EMR program from the ground up, and be able to re-design/adjust it easily without layers of bureaucracy and non-medical software programmers clogging up the works, YES: EMR could improve patient care.
I think the concept of “pre-existing conditions” is an annoying yet realistic component of determining which patients will likely consume a greater portion of the insurance “pie”. Now, if you have nationwide health care insurance that automatically covers all pre-existing conditions WITHOUT finding a way to compensate financially for the extra burden incurred by a diabetic-hypertensive-smoker, compared to a non-smoking healthy specimen of manliness (like myself), then the end result is: everyone pays the same amount into the pot (taxes), but some people will consume WAY more of that money. Fair? I think not. So then how do you make the math work out? Well, here’s an easy way: don’t pay the doctors equitably for the extra care and effort required for those complicated patients! DOH.
Requirement to have health insurance: I repeat, if nationwide health insurance has to cut back on reimbursement to doctors in order to make ends meet in the budget, why would any doctor want to accept that insurance? (“Will you be paying cash today, Mr. Brown, or will you be providing free car repairs for the doctor for the next month?”) So at that point, what good did it do to give everyone health insurance?
Research on the effectiveness of treatments = EBM (Evidence-Based Medicine). YES, I AM TOTALLY IN FAVOR OF THIS! It’s a concept which has really only showed up in med schools in the past 10-15 years , so the “older generations” of doctors still tend to use a lot of “in my experience” and “well I heard somewhere” (Anecdotal Medicine) to back up there current treatment practices without actually checking to see if the research backs it up! EBM is awesome.
But something else needs to go hand-in-hand with EBM in order for doctors to be able to practice medicine safely, relying on the research without having to worry so much about “But what if this patient is the 1 in a thousand/million patient that DOESN’T fit the research, and I get SUED?” — TORT REFORM. As long as patients can sue the pants/underwear/scrotal skin off of doctors because of a “random” unexpected poor outcome while attempting to follow EBM guidelines, doctors will continue to use the Shotgun Approach for patients: BLAST THEM WITH ANTIBIOTICS AND FULL-BODY SCANS AND UNNECESSARY HOSPITAL/ER VISITS AND TOO-SOON SPECIALIST REFERRALS, so that a future judge/jury can’t say “You didn’t do enough for this patient!” I can’t begin to estimate just how much $$ is WASTED each day by doctors ordering tests that won’t change their treatment plan, just to appease the patient (either because the patient is currently demanding the test, or because the doctor imagines the patient complaining later that the doctor DIDN’T do the test).
I have a colleague who regularly walks out of exam rooms with a throat culture swab, hands it to the nurse, and says, “Go ahead and do the strep test, but I’m sure it’s going to be negative.” 5 minutes and one pointless test later, he goes back in the room and tells the patient, “Well, it appears you don’t have strep throat, because the test was negative.” ARRGH! You already knew the patient didn’t have strep throat, based on your physical exam! But that’s Defensive Medicine for ya — doctors are running scared of patients and their lawyers.
(So this whole post makes me sound like a greedy elitist doctor. Not at all. Our country should not have so many un-insured patients — it’s shameful. But the current health-care-reform bill(s) are really “Health-Care-Insurance-Coverage-Reform.” Hence my skepticism.)
Hope this helps. Sorry I took a while to reply — I always procrastinate replying to these “political” questions, cuz I hate the whole topic. :p
Howdy — thanks for the compliment! Glad you’re enjoying my writing.
Congratulations on being a medical student, and not just any med student — but a med student that is actually paying attention to the Bigger Picture when it comes to the US Health-Care system. I really think the only way that we physicians, as a profession, are going to have any hope of revamping this mess is if doctors start getting educated and knowledgeable about the politics and economics of health-care from the get-go!
My thoughts on the state of US health care? Ok, here they come… (Just give me a moment to emotionally prepare myself to lose half of my Tumblr followers, who will inevitably disagree with me)
I’m not sure what exactly you mean by “the disparity between urban and rural practice”… can you clarify that question? Then I’ll try to answer it.
(Ugh, just writing about all this crap is giving me an ulcer and a headache.)