Sorry - long post. Here are the cliff notes:
1) We are already seeing more patients than ever before whether they pay us or not (EMTALA).
2) Other specialties are going to have the same thing happen to them (without EMTALA, but by basic economics) and catch up to us.
3) "Mandated" insurance won't be much "insurance"
4) Hospitals (our places of work) will be bought/sold/go out of business/consolidate rapidly in the next 2-3 years. Our contracts will remain as unstable as they are, possibly become more stable as administrators try to figure out what the hell is happening to them.
5) Hospitals won't want to admit as many patients, and will expect us to send more home, or place in "Observation Status". The medical staff will expect the same, and possibly blame our specialty for their lack of reimbursement. See #4 above.
6) Tort reform will not happen. We will continue to be sued at the same rate. Potential liability to general practitioners may increase on the Federal side.
7) We will have increased pressure from all sides of the playing field (Government, Hospital Administration, Local Medical Staff, Insurers) to do more with less, and make decisions against our training.
8) There is no clear definition for our role as a specialty in Obamacare but a combination of external forces will re-shape how our care is delivered and possibly what our "Standard of Care" will become.
____
From an outsider to other specialties looking in, I have heard everyone say "the sky is falling!" and "run for the hills!" The truth is, the sky is falling for THEM because they have never had to do what we have been doing for almost 30 years as a specialty - TREAT PEOPLE FOR FREE!
As has been mentioned many times in the past, our patient load will increase and so will our reimbursement. The basic product offered by "healthcare exchanges" amounts to little more than a medicare package at Medicaid level of benefit for the consumer. In my state, we will have four "tiers" of insurance, with the middle tier being comparable to private insurance (read Blue Cross/Blue Shield). This won't effect most private insurer premium prices because people will likely be able to afford these products as they do now. Employers may drop private coverage and eat the penalty, but these will likely be blue-collar / retail / food/beverage employers who's employees don't earn high wages to begin with. The net will likely be improved coverage for these people at lower cost. Also, traditionally, the age range of the people in these lines of business doesn't utilize the healthcare system as it is now.
The REAL impact that Obamacare will have on our specialty involves economy of scale and healthcare consolidation. Hospitals will be for sale, sold, or simply go out of business. Some will join together or be swallowed by a larger corporation. Privately-owned community hospitals without a large endowment or private fund source will be on the bubble. Affiliations between hospitals and local medical staff will take on a whole new meaning as the ACO model continues momentum.
We rely on hospitals and medical staff to keep us in business, and the name of our contract holder is likely to change more often than the contract for a given location. With every new owner comes a new threat to the individual ED contract, and in turn, these contracts may change hands as well - although hopefully at a slower rate than they are now.
Private physicians will not be reimbursed for patients who are readmitted within 30 days of discharge (Chest Pain, CHF, Pneumonia, and - starting in 2014 - COPD and Sepsis). They will not want us to keep their patients in the hospital. The Hospital will come up with creative ways to divert these patients in their system to keep them out of the "Inpatient" status. We will be at the mercy of their schemes and forced to "do the right thing" or have them "find someone who will." Again, the "right thing" has many definitions...
There is no clear provision for the role of EP's in the ACO model, and since we are (and have been) subject to EMTALA, we will continue to see every patient who walks in our door. It is likely that this is intentional, and that our volumes will go up because fewer private doctors will accept the lowest reimbursing form of government insurance. Patients will come to us for more non-urgent needs and we will continue to be mandated to treat them. Hospitals will put pressure on us for using THEIR resources (nurses, techs, CT machines, etc) for patients who "don't need care" and impose rapid medical screening exam processes to sort out the non-urgent patients. There will be no tort reform and we will have a larger "n" of patients to litigate against us. Urgent Care centers will begin popping up all over the place, and their owners will seek to take advantage of better reimbursement packages by insurers who want to divert their patient's from costly emergency bills. Patients (consumers) will realize that a $75 copay at the urgent care is less than their $250 copay in the ER and follow suit to be seen there.
There will always be the uninsured welfare recipient with dental pain for the past 3 months who NEEDS to call the ambulance to go to the ER for their molar today, because TODAY IS THE DAY, and no matter how many doses of Motrin we given them, they will continue to come back to see us. There is no amount of economic diversion, insurance justification, public education, or bureaucracy that will prevent this from happening and no, they will never pay their bill.
At the end of the day, everything will change for medicine, but not much will change for us overall, except a few more patients. Whether these changes are for the better remains to be seen.
