More health care regulations mean more middlemen, fewer doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Nov. 27, 2013

I attended the recent Hawaii 2013 Healthcare Summit, on how Hawaii is implementing the Affordable Care Act and transforming health care. The keynote address by Dr. Abraham Verghese was inspiring — all about the sanctity of the doctor-patient relationship and how health care should be focused on the living patient, not the “iPatient” in the computer.
In panel discussions, Hawaii’s health plans and hospitals told us how they will guide us away from fee-for-service payment that rewards volume of services to value-based payment systems that reward quality and care coordination. The goals are the “triple aims” of improved quality, improved population health, and improved value/reduced cost. However, dig deeper and the conference was full of contradictions and confusion.
Information presented included:
* Hawaii has a low rate of medical procedures compared to the rest of the country.
* We have the lowest per capita fee-for-service Medicare expenditures in the country.
* Thanks to relatively broad coverage under our Prepaid Health Care Act, Hawaii covers more of our population than any state besides Massachusetts — our benefits are already at the “gold” and “platinum” levels for Obamacare plans, better than any other state — yet we have the third lowest insurance premiums in the country, and all of this under a fee-for-service system.
* Hawaii has 20 percent fewer physicians than needed for our population and this is projected to get worse. Shortages are especially severe on the neighbor islands.
* Two-thirds of Hawaii psychiatrists no longer accept new Medicaid patients, many dropping out in the past four years, and our ER and hospital costs for mental illness have risen 30 percent in that time.
Hospitals and health plans were well represented on panels, but no practicing doctors. Doctors were shaking their heads as panelists told us that solo and small-group medical practices will soon become extinct, replaced by competing “accountable care organizations.” Every health plan and hospital now has multiple “partners” deploying computerized systems to enable them to better manage health care. Doctors are going to be rewarded for meeting quality metrics and punished with financial penalties if they fail to purchase computer systems that achieve “meaningful use,” or if they fail to meet quality metrics.
You would think from these presentations that the problem is doctors who don’t care about quality and just want to do more procedures and see more patients to make more money. The health insurance plans and hospitals are going to make sure doctors get paid for “quality,” not “volume.” However, there is no evidence for the alleged problem with excessive “volume” of services here, and if you look at the actual “quality” metrics, they are either very narrow, focusing on those limited aspects of health care that can be easily measured, or they are seriously flawed and don’t actually measure “quality.”
The managers and middlemen in health care are proliferating while our supply of doctors is dwindling. The evidence shows that doctors in Hawaii are not actually delivering much unnecessary care, but there are not enough of them and the ones we have are overworked and overburdened with administrative requirements. We are apparently pursuing Dr. Verghese’s “iPatients” at the expense of real patients.
Doctors agree that time spent on charting and administration is increasing, so they must work longer hours, spend less time with each patient, or see fewer patients. They are restricting their practices to fewer insurance plans to control administrative burdens, leaving more patients with inadequate access to care. Many are talking about early retirement or dropping participation with health insurance entirely, converting to “concierge” practices for those who can afford it. All of this is taking us in the opposite direction from the “triple aim” goals.
Most of our problems are problems with inadequate access to care, especially for those with Medicaid, not fee-for-service incentives or lack of concern for quality.
Hawaii’s experience with our Prepaid Health Care Act shows that broader coverage and improved access to care actually reduce health care costs. Let’s take this further and expand coverage to everyone, build our health care provider work force, simplify and streamline administration, pay doctors the same for everyone, and eliminate barriers to access care. Single payer, anyone?
Stephen B. Kemble, M.D., is a psychiatrist, an assistant professor at the John A. Burns School of Medicine and immediate past president of the Hawaii Medical Association.