This constantly came up in 2008 around election time, and then again when Obamascare was being debated in Congress. The thought by many of my ER colleagues that were in favor of Obama and his proposed plan was that if the government provided insurance for the uninsured "poor" in our country that currently have no insurance, that that would be a simple net gain for Emergency departments who had been unfairly burdened with taking care of the uninsured, all along. On the surface, it makes sense, with all other things being equal.
I and many others were very, very skeptical that the government would simply just give ERs more money for doing what what we were already doing. I simply put it in the category of "too good to be true". It's really a non-brainer. My feeling was and still is that there would be a big price to pay that would come in many forms:
1. Cutting payments from other sources (happening; see SGR, Medicare cuts, toxic/punitive Washington State Medicaid cuts)
2. Raising income taxes on the providers of care, NOT those receiving the benefits (proposed by Obama, blocked by Congress, certain to happen eventually)
3. Rationing care (has to happen; too many new insured, no increase in resources).
The feeling about Medicaid was always along the lines of, "Oh well, if we can collect 25 cents of the dollar it's better than nothing". On patients with no insurance you can bill them and maybe collect 25 cents on the dollar and get something for the care you provided.
What Washington state Medicaid has done is essentially completely take away these peoples insurance (for "urgent" care matters) and essentially rendered them uncovered and uninsured, but because they still retain the label of "insured" makes it illegal from you to bill them for the balance. They've rendered them worse than uninsured.
We always knew Medicaid was much worse than private insurance, but they've successfully done what even I thought was impossible:
They've made Medicaid worse than no insurance.
Truly amazing.
I really think this is only the beginning. I believe that governments will become increasingly more toxic to providers to a level that is unfathomable. It will not reverse itself until doctors have snapped to the point that a crisis occurs. I personally witnessed people dying of head bleeds because neurosurgeons said, "F--- it, I've had enough". Did it make sense that governments let the malpractice situation get so toxic to doctors that entire specialties left entire states?
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No.
But they did it anyways.
My point? Just like to neurosurgeons and OBs decided that enough was enough, and got the ball rolling with tort reforms in many states, it will take a crisis to reverse course on the toxic treatment of physicians in relation to abusive policies such as:
-Arbitrary cuts in payment to all physician specialties
-Crushing lower paid primary care specialties with increased overhead (Electronic Medical records and "meaningful use") who are overburdened with irrational medical school tuition debt and shrinking payments.
-Satisfaction surveys that were designed for a fast-food restaurant concept as opposed to a medical environment where the "best practice" isn't always the most "satisfying" to people without a medical background.
-EMTALA (forced service without required payment)
-Predatory liability environment (where frivolous suits take years and hundred of thousands of hours and hours and hours spent doing depositions and testifying to beat, with no disincentive to file)
-Joint Commission (irrational mandates such as blood cultures on all pneumonia, requirements to lock up antibiotic ointment in Med cart)
-Stark laws (that prevent doctors from owning hospitals, which results in people running and owning hospitals who have less medical experience than doctors, nurses, PAs, medical assistants, paramedics or even hospital volunteers)
-Physician anti-trust laws (which deprive us of something that all other Americans consider a "right", the ability to form unions, bargain collectively or strike as a means to protect ourselves from the listed toxic, dangerous and overly burdensome regulations )
-Uncompensated "medical screening exams" which expose doctors to toxic liability, and hurts patients by encourages doctors to quickly screen out non-emergent patients (who invariably in some cases will have underlying severe illness) to save money primarily, for the hospital or in the case of Washington and other states, government insurance programs.
-Focusing on 15 minutes "door to greet" times for non-emergency care as a quality measure as opposed to encouraging high quality care within peer defined standards of care and quality measures.
If anyone else has a solution of how to resolve the above problems without letting it get to the breaking point of a mass physician strike, or mass exodus from certain states, specialties or the profession as a whole, please post it here. I have no desire to rant on SDN for the sake of ranting. I don't think the Government of the AMA are going to offer any help for any of these issues. I think we're going to have to figure out how to fix things on our own. Lets brainstorm here.
