ObamaCare's threat to doctors.

• Author: Amerling, Richard
• Position: HEALTH BEAT

THE DEBATE RAGING OVER OBAMACARE has been carried on mostly by politicians, pundits, policy wonks and economists, with little input from those most intimately involved with delivery of health care--medical practitioners. Doctors too often have been marginalized as serf-interested. If that were true, there would be far fewer practicing physicians. Of course we are concerned with income, as are all taxpayers and businesses faced with rising costs and taxes. Unlike other businesses, however, most doctors are unable to pass on higher costs to consumers due to price controls on reimbursement. When costs outpace income, bankruptcy ensues. This renders discussions of autonomy moot.

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Autonomy, for physician and patient, is central to the medical profession and dates back to Hippocrates: "I will prescribe regimen for the good of my patients according to my ability and my judgment. I will keep them from harm and injustice."

To be fair, physician autonomy and the doctor-patient relationship, have been under assault for decades. This was an inevitable result of the acceptance of third-party payment by physicians, and was greatly accelerated by Medicare and Medicaid beginning in 1965, and the Health Maintenance Organization in the 1970s. Medicare and Medicaid sought to control costs by limiting reimbursement to physicians, payment to hospitals based on diagnosis, and by curbing payments for services it deemed "medically necessary." Practice was--and is--distorted by these interventions. For instance, faced with declining payment for services, doctors in the volume of services. This means less time per patient, declining quality, and greater reliance on laboratory services, imaging procedures, consultants, and hospitalizations. Total costs actually rise when physician fees are cut.

Health Maintenance Organizations promised to improve quality and control costs by assigning each patient to a primary care provider, or PCP. The PCP, who could he a nurse practitioner or physician, serves as a gatekeeper, blocking access to higher level care. They receive direct financial incentives to spend the least amount possible per patient. This is the opposite of physician autonomy, with the PCP in effect working for the HMO.

Whatever its final form, ObamaCare would perpetuate these failed models. In addition, it will include enhanced measures to control medical care. These will he implemented under the guise of quality assurance and cost...