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March 10, 2013

Working With Reality (tmi3rd)

Hi there, Morons and Moronettes. tmi3rd here, and in a break from weather, tonight's thoughts are about ObamaCare and working around the extremely onerous regulations now in place.

Much as I'd love to say we can realistically repeal ObamaCare, I'm not convinced our political leadership has the fortitude to do so. Under the circumstances, you're still going to need to be able to get hold of a doctor and get treated for what ails you in the immediate future.

The Wall Street Journal article that lays it out in its clearest form is hidden behind the paywall, so let's blockquote the key point:

"To keep costs low, the insurers are pressing for hospitals to grant discounts from the rates hospitals usually get in commercial plans. In return, participating hospitals would be part of smaller networks of providers. Hospitals will be paid less by the insurer, but will likely get more patients because those people will have fewer choices. The bet is that many consumers will be willing to accept these narrower networks because it will help keep premiums down."

Soooo... a pretty close approximation of HMOs and PPOs that went over so poorly in the 80s and 90s, and a very close approximation of how things work if you're insured by certain groups already in existence. You're covered if you see a doctor or receive a service within the network, but you're on your own if you go see someone outside of the network. Want to see more docs? It's going to cost you a lot more.


So let's jump to the doctor side of things. Most of the folks in the primary care fields- family medicine, pediatrics, internal medicine- are in situations where they have to see a certain number of patients in a day in order to make ends meet for that particular day. These fields don't pay terribly well for medicine (remember that we get out of school typically about $250K in debt), and the notion of doing assembly-line medicine for comparatively low pay is unattractive for a lot of new docs. We have to shuttle you in and out, meaning that you sit in the waiting room for an extra thirty minutes for thirty seconds of the MD/DO's time. Lose-lose for both sides- we don't get to know you, and you think we're a bunch of disinterested amateur golfers.

As a sidebar- some consider OB/GYN and emergency medicine (ER docs) to be primary care as well. For the moment, let's put that aside and return to the issue at hand.

The end result is that the shortage of primary care docs is going to be exacerbated by ObamaCare, and you're still going to need to be able to see a primary care physician somewhere down the road.

All is not lost, however, and here's where a silver lining exists: a significant number of docs in the primary care fields are jumping out of the traditional insurance-based model of delivering care and entering what many call concierge medicine- you pay a monthly or yearly fee to a physician, in return for having (in many cases) 24-hour-a-day access to your doc and a certain number of services and procedures that are part of that fee.

The cool parts about this for the doctors and patients are that it allows the docs to control how many patients they see in a day, which means they can spend more time actually treating the patient and spending time with the patient. Also, it allows the doc and patient to get to know each other well enough to actually establish some trust and a real relationship. Finally, a concierge doctor becomes your advocate with hospitals, should you need to be hospitalized.

Check this BusinessWeek article out for some examples, by the way.

Now here's the fine print: you still need health insurance for if you need to be hospitalized. Also, even though surgery is a lot cheaper if it's done with cash, you're still often talking about several thousand dollars (a lot of comparatively minor surgeries, for example), which most people don't have lying around.

We'll go into pricing and what not in a future post, but let's get to the bottom of this one: particularly for Morons and Moronettes approaching or at retirement age, concierge care is a really good idea. We're already in a position where we don't have enough doctors in geriatrics to begin with, and a good, long relationship with a primary care doctor can only benefit you if you get into trouble. Conversely, if you're younger or if you've got a young family, this can save you from a whole lot of inconvenience, especially if time becomes critical.It does mean that you pay out some more money for your care, but it beats the hell out of hoping that someone can make time to see you.

The somewhat ironic thing about this is that a very viable counter to ObamaCare would have been to have people pay cash for their primary care services, and leave insurance solely for things like surgery, emergency hospitalization, and so forth. That would likely have punched a big hole in what we pay out for insurance, but it's too late to cry over spilled milk.

The feds can certainly find ways to screw this up, of course. For example, licensure to practice in Massachusetts requires that you enroll in MassCare. If you want to do something to make sure there's still a private market carved out, petition your state legislature to pass laws decoupling state licensure from enrollment in ObamaCare programs. It won't stop the feds from being heavy-handed, but it will mean they likely have to go to court over it.

If we look at the other national healthcare systems out there (a phrase I detest, but it distinguishes their systems from our industry), what we may see is a situation where docs have to work a certain number of hours in public hospitals per week, and they can do private work the rest of the time. Conversely, an opthalmologist from Quebec I used to play hockey with would shut his practice down in the last couple of months of the year because the government refused to pay him for any more work. He moved down to Louisiana.

Anyway, finally, there are some groups that are worth monitoring in the interest of keeping that private side of medicine carved out... the Association of American Physicians and Surgeons are good people, as are Independent Physicians for Patient Independence. Check 'em out... in the meantime, I'll keep you posted as I get through medical school. I'm hoping to go into ear, nose, and throat surgery, but we'll see what shakes out.

I'm probably studying for my physiology test and the MCAT as you're reading this, so if you've got questions that I can answer, please come find me on Twitter.

Thanks, as ever, for reading!

-tmi3rd

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posted by Open Blogger at 05:24 PM

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