Obamacare: Prognosis Terminal

Health Insurance Exchange Fails its Physical

Politics and science work together about as well as politics and religion.
What about politics and education… energy… economics… ?
Come to think of it, politics doesn’t get along with anyone.
So it’s no surprise that problems arose when politicians got involved in healthcare.IMG_3979

This blog is not about politics. You’ve had enough of that.
I’m writing about access to primary care.

I’m a family doctor explaining why I won’t be a part of Obamacare.
And it’s not because of politics.
In fact, most primary care physicians are opting out.
Because we simply can’t afford to participate. I’ll explain why.

IMG_4122Primary care costs less than your cell phone. And more Americans have a cell phone than have a family doctor.  Obama gave away phones during his campaign.
Now, some politicians want to give away family doctors.
But we don’t take too kindly to being given away.

Here’s the thing. While educated and powerful people debate the failure of a website, the nuances of a law, and the moral obligation of a country to provide healthcare, most of them have overlooked the obvious. We are just flat out of primary care physicians.
Kaput. Empty. No room at the Inn.

Let me spell it out for you.

1) There aren’t enough primary care physicians to care for Americans.
Obamacare doesn’t help that. There is nothing in the Affordable Care Act to enhance primary care. Nothing to motivate more physicians to choose a career in primary care. No incentive to keep established PCPs in practice. Nothing to expand our offices or reward the wonderful people that work in them. No increased pay, no less paperwork, no fewer regulations. In fact, the opposite is true. We have more laws and taxes, confusing rules, and increased overhead.

2) Policies being sold by the Insurance Exchanges have very high deductibles.IMG_4111
Most Americans with insurance know that a deductible means that they will have to pay for the first $5000 of their healthcare. But the patients who can’t afford insurance, even if their plan is subsidized by the ACA, still can’t afford to pay their deductible. The ACA was to help those 30 million people who couldn’t afford insurance. But even if the insurance premium is tax subsidized, how will these patients be able to afford their deductible? By the way, that deductible happens in the PCP office. So who doesn’t get paid? The primary care physician.

3) Most hospitals are not even in the Insurance Exchange networks.
Once a deductible has been met, which is usually within the first few hours of a hospitalization, the hospital can anticipate getting paid. Even knowing that, most hospitals have opted out of over 2/3’s of the Exchange’s insurance plans. There are few things harder for a primary care physician than trying to find a hospital bed for a seriously ill “out of network” patient. It would be better for the patient to have gone directly to the hospital ER instead of to their PCP’s office. If a patient is already in the ER, the rules requiring a hospital to keep a sick patient could help. But doesn’t going to the ER first raise cost?

4) The preventive care coverage is very limited as to which services are covered.
All non-covered services will go to the deductible. Meaning the patients who couldn’t afford insurance must still pay for their illness care. Patients are confused by this and get angry at the PCP because they expected a “free physical”. When told that “your physical is covered”, patients bring long laundry lists of their medical problems that have been neglected. These need significant attention. Disease care is not covered as part of a screening preventive exam. The lab tests, and the physician’s time to evaluate these problems, are not “preventive care”. There is no provision for PCPs to be paid for this care. It goes to a deductible and primary care doesn’t get paid.

IMG_37485) If a patient doesn’t pay their insurance premium, the PCP must refund the insurance company. The Insurance Exchange policies have a 90 day grace period. A patient can sign up for insurance, see a physician between days 30 and 90, then chose not to pay their insurance premium. The PCP that cared for that patient will be notified by the insurance plan that the patient didn’t pay for the insurance, the policy is cancelled, and the PCP must refund to the insurance company all fees paid. If the PCP doesn’t refund the insurance company, the funds will be subtracted from the next payment. The insurance company is protected. The PCP bears the risk and takes the loss.

6) The earliest enrollees will be the sickest.
The young, healthy people that were “forced” to buy insurance are not signing up. The healthy seem to prefer paying the $95/year penalty instead of paying hundreds of dollars each month for a high deductible plan. Without the healthy enrollees, the price will soon go up. Meanwhile, overworked PCPs that participate in the Exchange plans will be assuming care for those patients who were sick enough to fight through the enrollment process. These are the patients that need the most care, or have neglected the most serious medical conditions. These patients have put off their care because they couldn’t pay for it. When the PCP delivers comprehensive care and expensive tests, those charges will go to the deductible. You see the pattern here. The PCP bears the cost once again.

7) Your PCP is already providing charity care every day.IMG_3828
Primary care physicians quietly provide free care in their offices every single day. We can’t advertise our charity because we would be overwhelmed. Everyone has a friend or a family member that needs free care. And unlike non-profit hospitals, no one subsidizes our charity. We can’t afford to market our giving, and we’re not very good at saying “no”. So like the thousand points of light that make our country brighter, we quietly tell a patient “no charge today” or “pay me when you’re able”. Warm handshakes aren’t taxable.

Primary care physicians have been caring for the uninsured and the underinsured for much longer than Obamacare. Primary Care is the greatest value in healthcare.
Now, more than ever, it’s time to remind our nation,
“We’ve been here for you, we’re still here for you. Let’s keep the politics out of it.”

Guy L. Culpepper, MD

12 thoughts on “Obamacare: Prognosis Terminal

  1. Really enjoyed this post. I have had several friends ask about the affect that ACA will have on the Doctors (PCP is too much of an “insurance” word for me – you earned Doctor and deserve the title). If the ACA is to be a success, it has to achieve its goals without killing the industry that is charged with providing medical services.

  2. Amen. I am a PA that has worked in family practice over 10 years now and this article hits the nail on the head. The only thing I would like to see added is tort reform to help protect PCPs from unnecessary lawsuits even when we follow the standard of care. Defensive medicine is expensive. With the government regulating us to death I can see about half the number of patients a day compared to even 6 years ago. If we did not deal with insurance and government regs, I feel we could likely reduce cost by %50, see more patients, and have MUCH higher job satisfaction. Thank you and God bless.

  3. I am a practice manager for my husband who is a board certified internist. We have lived the socialized medicine life in Mexico. Physicians have trained for a minimum of 12 years, and in some cases longer. My husband is a cardiologist in Mexico. His training has lasted longer since he had to go through residency here in the U.S. to become an internist. We provide the best care we can and for those without insurance, we have a fee schedule that allows them access to our services. This current administration has no idea what it means to have a medical practice, abide by all the rules (including those of the hospital which subsidizes us), be of service to the patients, etc. Physicians do not need more regulation piled on top of them nor do they need to be constricted in the care they provide. By the way, our daughter is in med school and now she is worried that she won’t get into a residency program because the government can’t think through the fact that there aren’t enough programs to accommodate the current volume of med students graduating next year. Maybe we should see if other countries need our medical services?

  4. Kudos to you Dr Culpepper. As a practicing ophthalmologist I can say that your points are not exclusive to Primary Care and that most all doctors are suffering with trying to come to terms with the mess this grotesque piece of legislation has created. Thanks again for taking time to make your points!

  5. My daughter changed her major from pre-med once it became clear that ACA was going to “‘stick”, deciding that she is not willing to incur debt and be in school for years with the high probability that she would not be able to recoup her costs, pay back her loans and have the autonomy to run her practice. Her pediatrician retired early rather than put up with the extra costs and regulations of the ACA that would render her practice unprofitable and more about adhering to regulatory burdens and less patient care. What politicians never seem to realize is that disincentives (taxes and regulations) affect people’s behaviors and as such, the producers in the economy change course.

  6. Awesome article Doc! I appreciate you taking the time to write the truth about Obamacare. I believe that the law is one of the poorest written, least thought out and more expensive in American history. Your insight as a very highly respected physician and primary care provider speak volumes about the inadequacies of Obamacare. I wish you and your practice the best!

    • Yes, physicians can opt out. The Insurance Exchange list policies from a handful of participating insurance companies, like Blue Cross Blue Shield. The insurance company must also sign up physicians, and hospitals, to participate in each plan. Nationally, many of the best hospitals, and best physicians, have opted out of all of these plans.

  7. Well said. The Devil’s in the Deductible. Enter the Jefferson Independence Card. Patients who use this simple time-of-service payment program have been and are increasingly becoming an important part of my practice. These patients are able to see their doctor without fear of unknown or exorbitant costs. My cash flow is improved, and insurance hassles and costs are nonexistent. This thing works.

  8. Well said. The Devil’s in the Deductible. Enter the Jefferson Independence Card. Patients who use this discounted time-of-service payment program have been and will increasingly be an important part of my practice. Cash flow is improved, and insurance hassles and costs are nonexistent.

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