An Obamacare Ineffective Premise
Stanley Feld M.D.,FACP,MACE
Obamacare’s goal is to improve the quality of medical care while reducing the costs of medical care. Big government believes it can accomplish this goal by controlling medical care using rules, regulations and guidelines.
My fear is Obamacare is just creating opportunity for secondary stakeholder to rip off the healthcare system.
The result will be higher costs of delivering medical care while lowering its quality.
President Obama and his administration must reexamine their premises and start thinking pragmatically.
Patients’ adherence to recommended treatments is a huge issue in assessing the cost of care. Obamacare does not provide incentives to patients to adhere to recommended treatments. If patients do not adhere to recommended treatment they will get sicker and cost the healthcare system more.
Obamacare’s emphasis is to change the payment paradigm to medical outcomes based system. Physicians and hospitals will be responsible for the patients’ outcome and be penalized for poor outcomes.
Patients’ adherence to treatment is less than 50%. Physicians have little influence on patient adherence.
“Physicians have always had to deal with patients who refuse to follow treatment recommendations, but this age-old quality and patient-care issue is about to become a pressing financial concern for doctors.”
The non-adherence rate of patients to treatment is anywhere from 30-60% depending on the disease, complexity of the treatment, duration of the treatment and side effects of the treatment.
The adherence rate also depends on the psychological state of patients at the time of treatment.
Patients who don't take their medications or don't adhere to treatment recommendations are at risk of getting sicker and requiring more services.
The added cost of care would come out of physicians’ reimbursement unless physicians know how to get around the rigid but inaccurate rules that measure outcomes.
Adherence to treatment is a vital part of correctly measuring outcomes. Nowhere in Obamacare’s rules and regulations is patient’s adherence to recommended care dealt with.
Some patients have perfected the art of non-adherence. I learned this early in my medical career.
Forty-six years ago I was working in the hypertension clinic at Parkland Memorial Hospital in Dallas. I had just arrived from the Massachusetts General Hospital where most of the clinic patients were caucasian Irish or Italian. There were a small percentage of black people in that clinic.
Ismelin was a popular antihypertensive drug in America at that time. Physicians did not have much else with which to treat hypertension. The problem with Ismelin was 25mg could cause patients to have orthostatic hypertension (blood pressure drops to very low level when standing) causing patients to pass out.
When I got to Parkland there was a high percentage of black male patients. Many were on up to 200 mg of Ismelin a day. I could not understand it. I got friendly with a couple of patients and told them that in Boston the dose needed was only 25 mg to treat high blood pressure. In Dallas patients received up to 200 mgs a day and were still uncontrolled. I asked if they had an explanation.
Three guys told me what the problem was. The chief of the hypertension clinic was very smart, a very good person, and very concerned about their health. He also had the pharmacy calculate the time these patients needed a refill.
The patients loved him for his sincere concern for their health. They would do nothing to hurt his feelings.
One 25 mg Ismelin pill would lower their blood pressure to intolerable levels. They would not take the medication or take it every other day or every third day. They knew he was counting the pills they took. They always refilled their medication on time. The medication was free to them at Parkland.
When they came into the clinic for an office visit their blood pressure was high. The chief would increase the dose to 50 mg a day and doses of up to 200 mg per day.
The chief did not understand why he could not control their blood pressure with these massive doses.
They told me after many months of friendship that 25 mg would affect their nature (sex drive and ability to have an erection). They did not take any of the medication even though they refilled it.
The moral of the story is patients will not tell you the truth at times and sophisticated measurements can fool you. The result will be bad outcomes and higher costs to the healthcare system.
This is only one example of non-adherence affecting outcomes. Uncontrolled hypertension is the primary cause of heart attacks and strokes.
Should physicians be penalized financially for patient non-adherence when there are many factors that affect patient non-adherence? Physicians will try to avoid treating non-adherent patients to avoid negative outcomes.
The growth of concierge medicine is the result of physicians desire to avoid government regulations, government decreases in reimbursement and government penalties.
Physicians will be cherry picking for the best and most adherent patients. The result will be a further shortage of physicians to care for the expanding Medicaid and treatment population resulting from Obamacare.
President Obama, please re-exam your premises and your policy wonks’ premises.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone
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