The “right” to health care vs. the right to earn a living
More fallout from the ObamaCare monstrosity. Reality begins to set in with a vengeance:
Want an appointment with kidney specialist Adam Weinstein of Easton, Md.? If you’re a senior covered by Medicare, the wait is eight weeks.
How about a checkup from geriatric specialist Michael Trahos? Expect to see him every six months: The Alexandria-based doctor has been limiting most of his Medicare patients to twice yearly rather than the quarterly checkups he considers ideal for the elderly. Still, at least he’ll see you. Top-ranked primary care doctor Linda Yau is one of three physicians with the District’s Foxhall Internists group who recently announced they will no longer be accepting Medicare patients.
"It’s not easy. But you realize you either do this or you don’t stay in business," she said.
For those slow on the uptake – when limited resources meet unlimited need, rationing is going to take place regardless of whether one wants it or likes it. Rationing can take effect in many ways. Two of the most common are by price and by availability (or a combination of both).
Declaring everyone is “entitled” to health care doesn’t make it more affordable or available. Because its availability doesn’t increase automatically on such declarations. And that was the fly in the ObamaCare promise from the very beginning. Then add in the absurd claim that you can get more for less and you’re where we are now with doctors and Medicare patients.
Reality is a harsh mistress. Reality says that a person will do what is necessary in the business world to keep their business going. We’ve seen that with the drop in employment during this recession as businesses cut back on headcount to survive it. The same goes with the business mix of paying customers any business has. If it takes a certain amount a month to maintain your practice, you have to ensure that is covered along with whatever profit (read salary) you want for yourself. The most common way a business does that, besides cutting expenses, is to raise prices.
But in health care you can’t really do that. So? So instead you change your business mix. You begin to refuse to see those who pay the least in favor of those who pay the most, i.e. less Medicare patients and more private insurance patients.
If you’re a doctor, you spent 10 years of your life getting to the position you now hold and even more years building your practice. You are, in fact, a small business owner who employs a good number of health care workers both directly and indirectly.
If however 40% of those you see are Medicare patients and those patient payments to doctors are being drastically reduced such that you’ll now be pulling in much less a month than you need to meet all your financial requirements, it is time to reassess the mix of patients you can afford to see. Note the word – afford. This is the only way a doctor can “raise prices”.
There are those who claim that such a doctor has a responsibility to see whoever comes in the door. In fact that doctor has many other responsibilities that preclude that – like his responsibilities to those he employs, the expense of his practice, malpractice insurance, student loan payback, etc. He can’t see the first patient until all of those things are paid for. And then he has to maintain his or her practice (thus the overhead) at a certain level to meet the needs/demands of the patients he does see.
So when he looks at his mix of patients, he has to make a decision, doesn’t he? And, as you see in the cite, many are beginning to make that decision. He has to get that revenue stream back up to the level at which he can at least cover minimum needed to sustain his practice at a level he deems necessary.
Among the top points of contention is the complaint by doctors that Medicare’s payment rate has not kept pace with the growing cost of running a medical practice. As measured by the government’s Medicare Economic Index, those expenses rose 18 percent from 2000 to 2008. During the same period, Medicare’s physician fees rose 5 percent.
"Physicians are having to make really gut-wrenching decisions about whether they can afford to see as many Medicare patients," said Cecil Wilson, president of the American Medical Association.
But statistics also suggest many doctors have more than made up for the erosion in the value of their Medicare fees by dramatically increasing the volume of services they provide – performing not just a greater number of tests and procedures, but also more complex versions that allow them to charge Medicare more money.
From 2000 to 2008, the volume of services per Medicare patient rose 42 percent. Some of this was because of the increasing availability of sophisticated treatments that undoubtedly save lives. Some was because of doctors practicing "defensive medicine" – ordering every conceivable test to shield themselves from malpractice lawsuits down the line.
Of course they practice preventive medicine because Congress has adamantly refused to address tort reform, so, in many practices the largest expense incurred per year is malpractice insurance. And naturally that constant threat drives the medicine to some extent. Additionally it is human nature to try to get what you believe your services are worth if you’re going to render them.
Instead we have an outside entity arbitrarily declaring what they’re worth. It is has now gotten to the point that providers have to make some decisions because they can no longer operate at the level they desire too with the payment structure in effect. And, as can be seen, they are making those decisions.
Which brings us back to the point that was made on this blog many times before when the promise of health care for all at lower cost kept being thrown around. You can’t have it both ways. The fact that there is now going to be more demand on a finite product means that rationing is somehow going to exist. The fact that you have insurance obviously doesn’t guarantee you a doctor.
Of course the reaction to these decisions is predictable as well:
Still, even if primary-care doctors had to rely exclusively on Medicare’s lower payment rates their incomes would only drop about 9 percent, according to a recent study co-authored by Berenson, who is also a fellow at the non-partisan Urban Institute.
"The argument that doctors literally can’t afford to feed their kids [if they take Medicare’s rates] is absurd," said Berenson. "It’s just that doctors have gotten used to a certain income and lifestyle."
Got the implied argument there? Whatever the income and lifestyle, they’ll just have to get over it and go along with the arbitrary price fixing government decides on. They’re probably among the “undeserving rich” Krugman was talking about below. Oh, and note that a 9% drop in income also means a commensurate drop in the amount of overhead the office can afford – headcount in other words. And that may mean poorer treatment.
You don’t get to decide what you’ll charge and let the market either reward or punish you for doing so. Oh, no. The government will decide on what is acceptable, private insurance will go along because it is worth their while (they may not match the cost but they’ll lower their payout because the government has lowered its payout), malpractice insurance will most likely rise (you can’t do a better job with less staff and less time) and there you are, captaining a sinking ship.
Of course the reaction being documented here is an immediate reaction to a flawed policy. It is as natural as self-defense, because in a business sense, that’s precisely what it is. Health care is a business, not a “right”. And this is how businesses react to such intrusions in the market that could conceivably kill their chance at survival.
Long term the result will be even worse and more drastic. And we’ve begun to see it already. With all the turmoil and cost cutting in the health care industry, fewer and fewer are choosing it as a career path. People like Berenson can sneer at doctor’s concerns now, but as almost every medical association out there has noted, fewer and fewer people are entering the profession. And that’s across the board. It seems, for whatever reason, our social engineers simply don’t understand economic basics and constantly and consistently dismiss them with disastrous results.
Incentive is a wonderful motivator that has brought us all sorts of innovation and a better life. Destroy that and you destroy motivation and the desire to excel. That’s precisely what is happening here – with predictable results.