Will there be emergency room overcrowding, rationing and orthopedic surgeon shortages as a result of the passage of the Affordable Care Act (ACA), known as Obamacare? What are the nonpartisan answers to these questions?
Photo courtesy of procon.orgProCon.org, a non-profit nonpartisan group. recently compiled responses to these 3 and 59 other questions about the new law from legislators and health care experts.
The 128-page review titled “Obamacare: A Nonpartisan Review of What It Is and What It Is Not” features 62 questions of which 39 have clear yes or no answers while the other 23 are debated using sourced pro and con responses.
You can read the entire 128-page review at either of these two options locations: Option 1 at procon.org or Option 2 at healthcarereform.procon.org
We picked out the pros and cons of the three questions asked above.
Emergency Room Overcrowding?
Won’t happen, say Cathy Bradley, Ph.D., and Sabina Gandhi, Ph.D., at the School of Medicine, Virginia Commonwealth University, and David Neumark, Ph.D., from the University of California at Irvine.
Photo courtesy Andrew Huth
Following a February 2012 study, they write: “Increased access to care is intended to reduce the unnecessary use of services such as emergency department visits and to achieve substantial cost savings.”
However, they admit there is little evidence for such claims.
So they looked at uninsured low-income adults enrolled in a community-based primary care program at Virginia Commonwealth University Medical Center. For people continuously enrolled in the program, emergency department visits and inpatient admissions declined, while primary care visits increased during the study period and inpatient costs fell each year for this group.
“Over three years of enrollment, average total costs per year per enrollee fell from $8, 899 to $4, 569—a savings of almost 50%. We conclude that previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage but that it may take several years of coverage for substantive health care savings to occur.”
John Goodman, Ph.D., President and CEO at the National Center for Policy Analysis, disagrees. In June 2010, he wrote: “More people are likely to turn to the emergency room for their health care and they are likely to do so more frequently under the new health reform legislation.”
He says emergency room costs will increase for two reasons: 1) about half the newly insured will enroll in Medicaid and Medicaid patients seek emergency room care more often than the uninsured, and 2) while the newly insured will try to increase their consumption of care, the absence of any program to create more providers will force patients to turn to emergency rooms as the outlet for increased demand.”
Lynn Massingale, M.D., Executive Chairman of TeamHealth, wrote this past June that the uninsured population has health care needs on reserve. He also says there is not a primary care practice excess in the country. “The odds are that newly insured individuals will not be able to see primary care practitioners and instead will visit an emergency room.”
Patient volumes in the emergency room are increasing as hospitals close and patients are consolidated into fewer ERs. Adding in an aging population will increase patient volume.
Independent Patient Advisory Board (IPAB) Rationing?
There will be rationing according to Wesley Smith, Senior Fellow at the Discovery Institute. In July 2012 he wrote: “IPAB’s unique ‘fast track’ authority divests Congress of discretion regarding the amount of money to be cut from Medicare once IPAB has submitted its ‘advice.’”
By January 15, 2014, IPAB must submit a proposal to Congress and the president which explains how Medicare will achieve its savings targets in the coming year. Congress has to introduce bills which also incorporate the board’s proposal the day they receive it. Congress cannot change or amend the report and all legislative committees must complete their evaluations by April 1st.
“If Congress does not pass the proposal or a substitute plan meeting the IPAB’s financial target before August 15, or if the president vetoes the proposal passed by Congress, the original IPAP recommendations automatically take effect, ” wrote Smith.
This past July, Steven Ertelt, Founder and Editor of LifeNews.com, wrote that the Department of Health and Human Services (HHS) will be empowered to impose so-called “quality and efficiency” measures on health care providers, based on recommendations by the IPAB, which is directed to force private health care spending below the rate of medical inflation.
“In many cases treatment that a doctor and patient deem needed or advisable to save that patient’s life or preserve or improve the patient’s health but which runs afoul of the imposed standards will be denied, even if the patient wants to pay for it, ” wrote Ertelt.
The law denies seniors the choice of private-fee-for-service plans whose premiums are sufficient to provide unrationed care but which HHS disallows. The law could therefore lead to elimination of the only way that seniors will have to escape rationing—by letting them pay for their own care.
No way, writes Ira Byock, M.D., Director of Palliative Care at Dartmouth-Hitchcock Medical Center.
“Many of the people I care for are incurably ill and need expensive medical care to stay alive. They’ve heard politicians say ‘Obamacare’ will take away their choices, rob them of hope for living longer and cast their fate to ‘death panels’ of faceless bureaucrats. Fortunately, none of this is true.”
He argues the law aligns financial incentives with high-quality treatment through Accountable Care Organizations (ACOs) and “transforms healthcare by making local health systems—made up of doctors, hospitals, clinics, laboratories and imaging facilities—responsible for the outcomes of care and the costs for the population of people they predominantly serve.”
“Accountable care has real potential for moving our system toward safer, more effective, and less wasteful treatments. Person-centered services, such as individualized care planning, thorough communication and coordination of care, ongoing monitoring, meticulous medication management and early response to problems, make economic sense.”
Reforming healthcare to make it rational is not the same thing as rationing, wrote Byock. “The best care gives people every chance of living longer and well.”
He cites the law’s language which specifically states that IPAB’s recommendations cannot “include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums…increase Medicare beneficiary cost-sharing (including deductibles, coinsurance, and co-payments), or otherwise restrict benefits or modify eligibility criteria.”
Physicians and Surgeon Shortages?
Yes, wrote Suzanne Sataline and Shirley S. Wang, of The Wall Street Journal in an April 12, 2010 article.
They write that experts warn there won’t be enough doctors to treat the millions of newly insured people. “At current graduation and training rates, the nation could face a shortage of as many as 150, 000 doctors in the next 15 years, according to the Association of American Medical Colleges.”
Source: Wikimedia Commons and U.S. Navy photo by Mass Communication Specialist 2nd Class Gary Granger Jr.
The U.S. has 352, 908 primary-care doctors now, and the college association estimates that 45, 000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.
Orthopedic Surgeons and Procedure Volumes
It’s not just primary care physicians.
Peter Pollack wrote in AASO Now in January 2009 that aging baby boomers and an increase in the number of obese patients will double the demand for arthroplasty over the next decade.
According to a paper presented by Thomas K. Fehring, M.D., at the American Association of Hip and Knee Surgeons 2008 annual meeting, decreased interest among residents in choosing careers in adult orthopedic reconstruction is likely to result in a shortage on the supply side.
Fehring found that 7, 585 AAOS fellows perform hip and/or knee arthroplasty, including 5, 973 general orthopedists with a hip and knee focus, and 1, 612 hip and knee specialists. The two groups perform a total of 337, 047 total hip arthroplasties (THAs) and 418, 542 total knee arthroplasties (TKAs) in one year.
Assuming orthopedic graduation rates remain stable between 2008 and 2016, Fehring determined that 1, 584 generalists with a hip and/or knee focus and 400 hip and/or knee specialists would enter the arthroplasty workforce.
Assuming surgeons retired at age of 59, 3, 338 generalists and 901 specialists would retire by 2016. This would result in a 31% decrease in the total number of generalists and a 32% decrease in the total number of specialists.
Fehring’s projections indicate that as many as 427, 500 THAs and more than 1 million TKAs will be needed by 2016. The orthopedic workforce, however, would only be able to perform 231, 071 THAs and 287, 759 TKAs in 2016. That’s a shortfall of 195, 929 THAs (46%) and 758, 241 TKAs (72%).
However, the American College of Physicians (ACP) in an April 2010 fact sheet says the new law includes numerous policies to train more primary care physicians and increase the supply of primary care physicians.
“These policies include: mandatory and increased discretionary funding for the National Health Service Corp (NHSC), reauthorization of Section 747 of Title VII, Training in Family Medicine, General Internal Medicine, General Pediatrics, and Physician Assistantship; creation of a Primary Care Training Extension Program and increased faculty scholarship loans, redistribution of 65% of the current unused Graduate Medical Education slots to primary care and general surgery and allowing residents to count their time spent in ambulatory settings to count towards their residency requirements, such as physician offices and community health centers; and the establishment of Teaching Health Centers, creating primary care residency programs in non-hospital settings.”
Unchartered Waters
We are in unchartered waters. Clearly demand will rise, surgeons are retiring and a broken public purse will require making choices of care, especially, as the current president of the American Academy of Orthopaedic Surgeons, John Tongue, M.D., has said, end of life care. Data will replace rhetoric as policymakers and providers learn the answers to these questions.
