Blog | Friday, October 25, 2013

Focus on Obamacare ignores the other health care revolution


While everyone has been busy losing their minds about Obamacare, people are missing the less visible revolution in American health care. This quiet revolution started years ago, and the basics are very simple: Shift costs away from insurers and place them in the hands of doctors and patients.

For patients (at least, the ones with insurance) this has meant a dramatic shift toward cost sharing as employers purchase less-unaffordable health plans. These plans, with their Byzantine system of moving more costs to providers and patients, are understood by no one except their creators.

Ask people who should know to explain the difference between “out-of-pocket,” “deductible,” “co-pays,” and “co-insurance” and you’re likely to learn nothing at all.

It doesn’t take a conspiracy theorist to find that the confusion generated is intentional. Most people look at how much money the benefits will pull from their paycheck and move on to trying to make ends meet.

The kind way to describe this is increasing patients’ “moral hazard” by giving them a personal stake in their health care costs. What I actually see in my office is people putting off necessary care for fear of large bills. (This seems to happen whether or not the service is actually “covered”. Most people I see don’t understand their insurance well enough and simply act in a way to avoid potential bills.)

But insurers aren’t just shifting costs to patients. An increasingly complex system of “incentives” is taking over doctors’ payments, making our current “fee-for-service” system even less comprehensible. The idea is a good one: Shift from paying doctors for how much they do, which may drive up costs since doctors get paid for “more,” to paying doctors for meeting certain goals. These goals are supposed to encourage doctors to focus more on quality than on volume.

In the trenches of everyday practice, it’s not working (or, if you’re more suspicious, it’s working perfectly by cutting doctors’ pay). I received a spreadsheet last week explaining my “incentive” payments from various insurers for the last quarter. From what I could tell, I made more money because I prescribe few brand-name drugs, but lost money because the number of my patients who went to the hospital was arbitrarily “too high.”

I can control whether or not I give proper advice to diabetics (something hard to measure), and whether I prescribe proper drugs to them (something marginally easier to measure). I can’t, however, control how often they go to the hospital. No one has shown that penalizing doctors for admissions or ER visits improves the care of their patients. No one has shown that these admissions measure how “good” a doctor is.

At the same time, each insurer has their own program of incentives, leaving doctors to steal time from their patients and their families to try to puzzle through the often contradictory requirements.

No one knows what Obamacare is really going to do to American health care. It may be a disaster, a boon, or more likely a bit of both. But fighting about it distracts from the on-the-ground reality: Primary care doctors, already in short supply, are being squeezed from every direction. As more Americans become insured, fewer doctors will subject themselves to the inane chaos of reimbursement. The only important question left is “Cui bono?”

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.