How Obamacare forced a two-tiered system

There is an excellent piece in the Wall Street Journal that explains how the ACA (or as everyone knows it, Obamacare), has forced a two-tiered health care system.

One of the key things to recognize is that physicians did not choose this model, we are just predictably reacting to it.  I know that I, and many physicians I know, warned that Obamacare would DECREASE access to physicians.

The heart of the matter is two-fold:
1. Absurdly low payment.  The Center for Medicare and Medicaid services has acted in a bullying, unreasonable manner in terms of the extent and levels of their cuts.   They were already paying lower rates than private insurers, and they continue to cut rates to levels that are unsustainable.
      Giving some specific examples, one of our most commonly performed procedures is an ultrasound-guided injection.  Medicare was already paying less than other insurers, and then cut payment by another 61% at the beginning of 2014.  This was not a negotiation, mind you, they simply made the unilateral decision to cut payment.
     Similarly, as my colleague Ethan Colliver noted in his excellent interview, cervical epidural steroid injections, depending on setting, are paid $40-50 per injection.  This is less than a massage therapist makes, and this is for a potentially dangerous procedure that requires a high level of skill.  In many cases, this may not even cover the cost of our liability insurance to perform the procedure.
      It is not hyperbolic to say that the Mafia is more generous in their interactions with their "clients."  I know that patients in the Medicare demographic are amongst my favorite patients.  This includes people like my parents, or some of my favorite patients like Margie McMaster, with whom I promised I would grow old together.

2. Increased compliance costs.  Medicare money is dirty money- it comes with a level of requirements that no other payor demands.  The most egregious aspect is that Medicare uses "Recovery Audit Contractors", who are bounty hunters that review physician charts to find ways to deny payments, threaten physician licensure, and potentially criminalize physicians who are trying their best to meet the compliance requirements set by CMS.
       In addition to the unpleasantness of being forced to click buttons instead of listening to patients,  it creates a sense of paranoia that no matter how hard we work to be in compliance, small errors could lead to devastating financial penalties that are out of our control, or an inability to continue practicing as a physician.
       Physicians have attempted to adjust to the increased compliance requirements by taking hundreds of hours of continuing medical education to learn more about Medicare requirements (..... time that otherwise could have been spent learning more about how to treat patients- think of the opportunity cost!), and this is problematic for Medicare.  We are not supposed to succeed!  Medicare is underfunded, and now depends on fining physicians to stay solvent.  So they introduce increasing complex regulations, like ICD-10 (which the new diagnostic coding system), realizing that if they make it impossible for physicians to comply, the don't have to pay physicians there already substantially cut fee schedule.

The combination of low pay and deliberately unworkable compliance system is untenable.  For many senior physicians, the solution is to retire early.  For others, it's to leave medicine.  For many future doctors, the decision is to not enter medicine in the first place.

..... and for the very best physicians, who have a choice in the matter, it's stop taking Medicare.

Patients, however, have a choice.  If you didn't like your experience with a commercial insurance carrier like Aetna, Premara, Regence, Cigna, or United, you could write to the insurance company leadership and let them know that low-balling physicians and increasing their compliance requirements hurts you as a patient.

It so happens that for Medicare, your "insurance administrator" is your congressman.  So write them!  Let them know that what they are doing to physicians is not right, and it causing you to lose access to the best doctors.   Congress has made it clear they don't care what physicians think.  Hopefully, they do care about patients, since ultimately, they work for you.