On the Cost of Healthcare, continued

Monday Musings for Monday April 29, 2013

Volume III, No. 16/119

(Editor’s Note: This week’s Monday Musings is written by pulmonologist Dr. Theodore R Kunstling, Medical Director, Duke Raleigh Hospital, Raleigh NC).



By Ted Kunstling, MD

The Patient Protection and Affordable Care Act (PPACA) signed by President Obama on March 23, 2010 seeks to achieve at least two major objectives: extending health insurance coverage to millions of uninsured Americans and controlling the rise of health care costs in the United States. How has the PPACA affected health care professionals so far?

Most health care providers agree that our current system of payment is broken, while most voters covered by employer or government- provided insurance remain satisfied with their own access to care, if not their increasing out-of-pocket expenses. The health care policy debate has been transformed by politicians into one of pitting increased access to care against controlling costs and reducing the role of the government in society. The Republican-controlled N.C. legislature has refused to allow expansion of Medicaid coverage to 500,000 uninsured placing financial stresses on hospitals which had counted on these funds to offset Medicare reductions. A serious viable alternative to ObamaCare has yet to be proposed.

Meanwhile, inevitably, the world of healthcare providers is undergoing radical transformation. Congress has mandated “meaningful use” of electronic medical records (EMR), before their value has been convincingly demonstrated. Local hospitals, beginning with Duke University Health System, are all adapting the Epic EMR at a total cost sure to exceed $1 billion. Value Based Purchasing will tie reimbursement to the results of publically reported patient safety and satisfaction data. The staggering costs of complying with these mandates are driving physicians to become employees of large hospital- centered entities which possess the capital and administrative expertise necessary to survive. As debates rage, private practice is being supplanted by centralized control of the medical profession by the government and large private entities, goals they have long sought as necessary to achieve control of costs.

Thus, physicians are rapidly entering a brave new world. Their masters in the new system have different values from those traditionally held by medical professionals. Return on investment rather than community need determines which services are offered and where facilities are located. Patients, astutely defined as “sufferers” by Robertson Davies in his novel, The Cunning Man, are regarded as customers.  Entertainment and service companies such as Disney and Southwest Airlines become role models for serving our customers. The teachings of the giants of medicine, such as Osler and Stead, seem drowned out by advertising. Physicians are issued new sets of values, are instructed what words may or may not be used in medical records, and are scripted in how to speak to their patients.

The future is uncertain, but a consensus is growing that renewed leadership by physicians will be essential if a way is to be found to expand access to care and create greater value at the same time. Hospitals such as Duke Raleigh have begun to prepare their medical leaders with the skills and knowledge necessary for them to have a seat at the table, to contribute meaningfully to ‘the pool of common knowledge.’


*Assad Meymandi, MD, PhD, DLFAPA is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.


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