(Editor’s Note: Read Dr. George Andros’ introduction to this installment of Veith’s Viewpoint.)
The Affordable Care Act (ACA) has the laudable goals of extending health care insurance coverage and reducing overall health care costs. However, hidden in the more than 2400 pages of this bill are a number of provisions, many still unrecognized, which will have detrimental effects on our national economy and the quality of care our health system delivers to society.
One such damaging initiative within the ACA is the thrust to increase the reimbursement for primary care providers and to compensate for this increase by decreasing reimbursement to specialty care providers. Is this a good thing?
Yes, we will need more primary care physicians to do what they do for our increasingly elderly population. The ACA will provide a financial incentive to increase the numbers of such physicians. And yes, health care costs are spiraling upward, and part of this spiral is due to the over-utilization of coronary, carotid and lower extremity stents and other procedures in patients who are not benefited by them or who are actually harmed by them.
Such over-utilization was recently documented in the lead article on the front page of the New York Times (August 7, 2012). This over-utilization of specialty care may be diminished somewhat if the guilty specialists receive less compensation per case.
However, the decreased specialist reimbursement may also have the paradoxical effect of prompting the unethical specialists to do even more unnecessary cases to maintain their incomes. There should be better, more direct ways to stop unnecessary procedures than shifting specialist reimbursement to primary care physicians.
Restoring ethical behavior to physicians and considering how best to modify the reimbursement system to be a disincentive to such bad practices are beyond the scope of this commentary. However, we should examine more carefully the negative effects and unintended consequences of shifting specialist reimbursement to primary care providers.
To do this we have to examine the question: “Who today gets patients who are really sick with an organic problem well?”
It is not primary care physicians. They play valuable roles in preventive medicine, in providing simple care, in comforting and reassuring patients while their self-limited disease runs its course, in recognizing serious illness, and in directing patients to appropriate specialists when needed.
Many of these functions, although very valuable and necessary, could be fulfilled by a trained nurse practitioner or a physician’s assistant and do not require a highly paid primary care physician.
On the other hand, in today’s high tech and complicated medical world, it is the highly trained medical specialist who gets patients well when they have a serious life- or limb-threatening illness. Such skilled specialists can place a coronary stent to prevent or treat an otherwise fatal or disabling myocardial infarction.
Other specialists can ablate a focus of an otherwise fatal cardiac arrhythmia. Still others can exclude an aortic aneurysm before or after it ruptures, or revascularize and save a severely ischemic limb. Other specialists can remove a variety of cancers, reconstruct a destroyed hip or fix other serious problems within the head, chest, abdomen or other parts of the body.
These skilled specialists have to work hard and devote years and long hours to be trained and to maintain their skills. They have to be available 24/7 to provide emergency treatment when minutes and hours make a difference, and they have to take the risks of failure including exposure to medical liability. For these skills, risks and their commitment, they deserve to be highly compensated in keeping with other professions that have similar requirements.
If reimbursement to such specialists is diminished, clearly the level of care that they provide – the care that really makes a difference to patients – will also be diminished. We will be sacrificing the geese that lay the golden eggs of medicine in the U. S. today, and health care will suffer.
This unintended consequence of diminished specialist reimbursement has occurred in other countries where specialists are underpaid.
Thus, as we go about the difficult task of reforming our health care system, decreasing unnecessary procedures and cutting overall costs, we must be sure to preserve what is great about our system and some of the exemplary care it provides. Most of this care is delivered by specialists, and we must be careful to continue to motivate them appropriately.
Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.
The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.