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Commentary: ACA would lead to end of physician-patient relationship

This article first appeared in the St. Louis Beacon, Oct. 12, 2012 - Physicians today face very uncertain times.

Reimbursements from insurance companies and Medicare fail to keep pace with rising costs of practice. We are converting from paper charts to electronic health records — at a burdensome cost of over $90,000 per physician, no matter what practice size. Looming on the horizon is performance-based medicine in place of the traditional fee-for-service model.

Malpractice insurance rates in Missouri are likely to rise in the wake of a recent court decision overturning caps on non-economic damages. Facing these pressures, many private-practice physicians are selling their practices to hospital systems, changing the landscape of how and where patients access their physicians.

Another major problem facing physicians is the implementation of the Patient Protection and Affordable Care Act. Twenty-seven hundred pages of legislation and 10,000 pages of added regulation will make the health-care system more confusing for physicians and patients alike.

We all agree that some type of reform has been needed. Too many people are uninsured or underinsured, and either go without needed care or are left with medical bills they cannot afford. Many show up in emergency rooms for routine care or when their medical situation is out of control. There are shortages of physicians in some fields, particularly primary care.

But all physicians also agree on the importance of the doctor-patient relationship.

As physicians, we take an oath to uphold and protect the health of our patients. The doctor-patient relationship is fundamental to achieving this goal. The physician and the patient should have the authority to decide what course of treatment is best for the patient, without dictates from outside forces, whether it be insurance companies, government or some other entity. The care of our patients cannot be entrusted to anyone else.

This is where PPACA is most problematic. Health-care control under PPACA changes the doctor-patient relationship to one of a government-patient relationship. Physicians will be increasingly burdened with government regulations that will dictate diagnostic protocols and treatment modalities. Which patients will be entitled to which treatments will be prescribed by the government cookbook, and the overriding concern will be cost, not necessarily quality.

The complexity of PPACA makes me doubt that it will survive the test of time. The alternative payment modalities in the bill, such as Accountable Care Organizations, may not succeed. If they fail, will we be past the point of no return? Will enough physicians, hospitals and insurance companies remain to pick up the pieces? If not, will the only alternative be a single-payer government system? If so, the doctor-patient relationship will be extinguished, as physicians will then become merely agents of the federal government.

If one entity, such as the federal government, is the sole payer for health care, then that entity becomes the owner of not just our health care, but our bodies and souls. That entity will have the ability to restrict our basic freedoms to choose our behaviors and our very lifestyles.

Are there alternatives to PPACA? I believe a more consumer-driven model of health-care reform would be much more appropriate. Health savings accounts and high-deductible insurance plans should be promoted for those fortunate enough to still be employed in this economy. Tax credits for the uninsured or underinsured should be considered for those who do not have the ability to pay for their own insurance.

Vital to this discussion is also the necessary reform to Medicare. Medicare is insolvent, especially with the baby-boomers now reaching age 65. PPACA does not address this issue. We cannot afford to continue to vilify any politician who brings up this subject with the disparaging “He wants to take away Granny’s health care.” Without open discussion, this problem will never be solved, and Granny will lose her health care. A consumer-driven model with a Medicare fixed-benefit should be on the table for consideration.

As our nation proceeds with health system reform, the following issues must be addressed:

Americans should be free to choose and privately contract with their physician and hospital. This is part of protecting the doctor-patient relationship.

Health insurance should be more affordable and accessible. Patients with pre-existing conditions should not have coverage denied or be burdened with exorbitant premiums. Health insurance should be portable and not tied to specific employment situations. There should be a free market, with competing plans available and patients having the ability to purchase insurance across state lines.

Reimbursement to physicians by government-sponsored programs should be set at rates that allow all physicians to sustain their practices. Without reasonable compensation, we will continue to see physicians retiring or leaving practice.

Meaningful tort reform should be adopted that addresses the high costs of lawsuit abuse and defensive medicine, with reasonable limitations on frivolous lawsuits and unrealistic judgments. PPACA does not address tort reform; this is another large shortcoming of the law.

It is a challenging time for medicine. The future may bring a system that enables us to promote better health for our patients or one that leaves serious shortcomings. In crafting a reform of the health system, it is critical that the concerns of physicians be addressed. The core of our health system must continue to be the doctor-patient relationship, where together the physician and patient make informed decisions about the best course of treatment.

Stephen G. Slocum, M.D., is an ophthalmologist in private practice in St. Louis. He is the current president of the Missouri State Medical Association and is a past president of the St. Louis Metropolitan Medical Society. This article is his personal opinion does not represent the positions of the Missouri State Medical Association or the St. Louis Metropolitan Medical Society.

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