Stanley Feld M.D., FACP, MACE Menu


Uncertainty Leads to Ineffectiveness

Stanley Feld M.D.,FACP,MACE

The implementation of Obamacare has progressed at a slow pace because of the Obama administration’s lack of understanding of physicians’ and patients’ needs.

In order to adjust to plans and policies not working as the Obama administration visualized, the administration has had to adjust policies, plans and costs.

There is no question in my mind that medicine is primed for a new age because of the advances in science, information technology and medical technology.

In my view Obamacare is a bad law. It is inhibiting progress on these upcoming advances. President Obama is trying to control provider behavior by measuring it in microscopic detail. He is trying to shift the cost and risk of patient care to physicians and patients in order to reduce costs by decreasing risk to the healthcare insurance industry.

He is trying to commoditize patient care. Obamacare is destroying the patient/physician relationship.These relationships are vital to the therapeutic index of any treatment.

Many of the Obama administration’s policy adjustments have led to uncertainty. Uncertainty of ad-lib changes in policy inhibits progress, increases costs, and produces anxiety and inefficiency.  .

One delay that has immobilized physicians has been the constant changing of implementation dates for ICDM-10 from ICM-9. Physician offices, physician groups and hospital systems are way behind in having fully functional computer information systems.

For many, the computer systems are too expensive even with President Obama’s promise of financial supplementation. It is difficult to change coding for treatment and procedures from 18,000 codes to 88,000 codes.

The reason for this coding change is for government to evaluate the work of physicians and hospitals microscopically in order to determine how much to pay them.

The government does not trust physicians. Physicians do not trust the government. In order for any system to work effectively and efficiently there must be mutual trust. Absence of mutual trust leads to more fraud and abuse, not less   

 The uncertainty about this year’s “doctor fix” is another example of uncertainty. 

In 2003 the government set up a defective measurement system intended to reduce physician reimbursement by about 5% per year. Each year the congressional “doctor fix” relieves physicians of the decrease in reimbursement from Medicare.

The SGR formula makes no sense. Medicare has reduced physician reimbursement to physicians as physicians' expenses have increased.

President Obama promise the AMA he would SGR problem.

However, each year’s “doctor fix” is cumulative. This year physicians face a 30% decrease in reimbursement despite the fact that many reimbursement codes have decreased reimbursement yearly in addition to the looming 30% decrease in reimbursement.

The policy has led physicians and physician groups to hold off on investing in coordinated care and technology. Additionally, physicians have a dim view of their return on investment for two reasons. Physicians cannot pass the cost of these new systems on to patients or the insurance industry because of the government’s pricing policies and because the government does not pay for much of the coordinated care or education of patients with chronic disease.

As a result of this uncertainty and anxiety physicians are selling their practices to hospital systems. Many physicians are salaried. These physicians figure the hospital system can have all the aggravation.  Other physicians are paid a salary plus a bonus determined by productivity. This does not eliminate the complaint that physicians have incentive to do more testing.

Many hospital systems have taken advantage of physicians’ intellectual property and surgical skill over the years. There has been a tradition of local adversarial relationships between physicians and hospitals. The hospitals’ tactics have not been obvious to many physicians. Many hospital policies are not transparent to their hospital-based physicians.

However, when it becomes apparent, the animosity between the physicians and hospitals becomes deep seated. The passive aggressive behavior of physicians inhibits the hospital system’s growth and development.


The Obama administration is discovering how difficult it is to form Accountable Care Organizations (ACOs).

The defects inherent in the purpose, formation, risk and implementation of ACO’s adds to its lack of success and the constant delays in implementation.

Obamacare has increased the number of Medicaid patients. Once these patients are on Medicaid, they cannot find a doctor.

President Obama had increase Medicaid payment to Primary Care Physicians in order to encourage more physician participation in Medicaid.

Physicians were hesitant to take Medicaid patients because this increased payment was temporary. The PCPs would be stuck with many low reimbursed patients.

“Kaiser Health News noted, the increases were temporary, so doctors had little incentive to alter their practices.”

This year the temporary Medicaid reimbursement increases have expired. The Medicaid rolls have increased. The PCPs were correct.  President Obama did not fix the Medicaid doctor shortage. It has only made it worse.

The number of physicians seeing patients with Medicare coverage has also decreased because of decreases in Medicare reimbursement despite the upcoming 30% decrease in Medicare payment.

President Obama ’s recent unilateral decision to alter immigration policy and provide these immigrants with healthcare insurance will only make things worse.

The ad-lib change in healthcare policy is driving physicians crazy. Many are frightened about their professional future in practicing medicine. 

There is a pervasive bias in Obamacare that favors hospital ownership of medical practices. The call for payment reforms and the call for coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors.

Where are patients’ feelings and needs in all of this? Patients are the commodities in a lucrative business that benefits secondary stakeholders.

The healthcare system as an efficient and effective healthcare system is destined to get worse because of the underlying uncertainty created by Obamacare.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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