Friday August 1, 2014
Originally published in FORBES.com
In the unfolding drama that is Obamacare, the current scene focuses on the law’s looming premium hikes. State insurance commissions are currently analyzing and releasing their expected premium rates for 2015. The early diagnosis isn’t good: Premiums are increasing almost without exception, with some states seeing spikes as high as 20 percent.
But from my perspective as a doctor, there’s another Obamacare storyline that deserves top billing. This subplot involves potentially radical changes to how doctors choose patients—changes that may even violate the Hippocratic Oath.
At the end of 2014, the Centers for Medicaid and Medicare Services will start penalizing doctors, hospitals, and other health care providers for not participating in the Physician Quality Reporting System. Originally introduced in 2007 as a voluntary program, PQRS asks providers to report on their compliance with pre-approved treatment paradigms for their Medicare patients. Doctors must obtain various health data on at least 80 percent of patients, which they must then submit to CMS. Until 2014, providers who met this goal received a monetary bonus.
This is a dagger aimed at the heart of medicine—it can perversely encourage doctors to limit the number of patients with complex medical problems they see. Why? Because those patients may need treatments that fall outside the program’s cookie-cutter protocols or they may require lengthy and frequent attention. This may jeopardize a doctor’s ability to meet the PQRS quota. Potentially affected patients may have conditions including diabetes, cardiovascular disease, etc., all which can make the management of a patient’s other medical conditions more difficult to treat.
This is wholly incompatible with a doctor’s promise to put a patient’s needs above our own. It turns a doctor into a practitioner of data extraction, when we should instead be focused on our patients’ well-being. Thankfully, the vast majority of doctors, myself included, refused to participate in this farce.
Enter Obamacare. It forces the majority of doctors to join PQRS by levying a penalty on non-participating doctors. (It also eliminates the bonus). The penalty starts in 2015 at a 1.5 percent cut on a doctor’s Medicare reimbursement rate, rising to a 2 percent cut in 2016 and beyond. While the program is still technically voluntary, Medicare’s low reimbursement rates give most doctors little choice but to give in to this financial coercion.
Every doctor who works at a hospital or anything but a private practice—a percentage that increases by the year—will have no choice but to participate in PQRS reporting. The only way to avoid it will be to refuse to accept Medicare—something that a growing number of doctors, including myself, have done.
Unfortunately, this isn’t the only example of an Obamacare regulation that potentially leaves some patients out in the cold.
CMS recently began assessing a penalty for hospitals that readmit too many Medicare patients within 30 days of their initial treatment. While the reasoning behind this is straightforward enough—doctors must not be doing their job if their patients frequently return with the same problems—it fundamentally misunderstands that every patient has unique medical needs. This simple truth means that some patients may require more frequent treatment, particularly if they have a recurring or rare medical issue.
Yet absent any nuance, the CMS rule leaves doctors with a financial reason not to see the patients who need help the most. In the future, patients with diabetes, high blood pressure, heart disease, and other serious medical issues may find it increasingly difficult to find doctors willing to take care of them.
It’s a similar story with Obamacare’s January 2014 revamp of the Evaluation and Management Coding system, the billing process used for Medicare patients. Prior to the law, E&M utilized five different codes for hospital clinic visits, which scaled reimbursement rates based on complexity.
In January, CMS replaced the five-code system with a single code and a single reimbursement rate for all hospital-employed physicians. In my field, for instance, a doctor who spends a few minutes getting wax out of someone’s ear gets paid the same as a doctor spending an hour evaluating, planning surgery and counseling a patient with an extensive skull base tumor.
This is little different than the changes to PQRS. It incentivizes doctors—and the hospitals that employ them—to prioritize quick and simple patient visits over long and complex procedures. As elsewhere, the government is placing financial incentives over patient well-being. This, again, punishes doctors that take care of patients who need medical care the most.
When I became a doctor, I swore to uphold the Hippocratic Oath. So did every other doctor. In so doing, we promised to put our patients’ needs above our own. Yet under Obamacare, bureaucrats in Washington are trying to make us break that promise.
This isn’t health care reform—it’s a tragedy. For our patients’ sakes, I hope it ends soon.
Dr. Gerard Gianoli is a private practice neuro-otologist from Covington, Louisiana.