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Can we afford more unintended consequences?


Within days of  President Trump’s Executive Order on protecting and improving Medicare for our nation’s seniors, more than 20,000 — including many physicians — endorsed a grassroots petition from Susan Hull and myself that, while supporting most of the order, warned against the consequences of Section 5. The Texas Medical Association and the Medical Society of the State of New York have echoed the concern raised in the grassroots petition. 

So, what’s the problem with Section 5?

Doctors, as veterans of healthcare battles in which unintended consequences and collateral damage abound, see Section 5 as a Trojan Horse crafted by special interests that seeks to increase the corporate consolidation of American healthcare, undermine competition, and fatten their own coffers.

Specifically, Section 5 calls for pay parity under Medicare — more accurately, “reimbursement parity” — between exhaustively trained physicians and less-trained (and sometimes very questionably-trained) mid-level providers — nurse practitioners (NPs) and physician assistants (PAs). Medicare dollars, and eventually all third-party payments for care, would be leveled (flattened) across physicians, NPs, and PAs.

Inevitably, Section 5 will accelerate the replacement of physicians by NPs and PAs, deepen “DRexit,” and make it ultimately pointless to take on the rigorous challenges and debt of becoming a physician. 

In this brave new world, it will be left to patients to figure out what has happened and to find providers with the level of training they prefer. 

And when it comes to costliness, here’s the kicker: After Section 5 is fully implemented, in a world where there won’t be much choice left, the choices that are left will actually drain more and more from the public treasury and private wallet.

How could that happen?

American healthcare is being consolidated. It’s becoming corporate, “big-box,” and anti-competitive.

The trend of consolidation has created two types of huge corporate players — regional hospital systems and pharmacy chains, such as Walgreens and CVS, that engage in more and more mergers and acquisitions.

Regional hospital systems now employ the majority of the nation’s physicians.

They swallow up independent competition and corner local markets.

It’s already established that regional hospital monopolies have been a costly trend for the public.

Their behavior, in some cases, particularly their treatment of the disadvantaged, has shown a disturbing indifference to public welfare.

They collect equalized, leveled reimbursements from Medicare, and pay their employees from those revenues, at least in part.

Why, then, would they continue to pay the salaries of physicians, when they collect flat amounts for the same work from cheaper replacements?

In short, the large, regional hospital systems will be incentivized by Section 5 to replace physicians with mid-level providers who can be paid less. The trend is well under way.

Huge pharmacy chains have used mid-level providers exclusively in their “health hubs.”

They have been building alliances with Pharmacy Benefit Managers (PBMs), the entities who control which medications are covered by third-party payers.

We already know the following about PBMs: they collect legalized kickbacks, they help themselves to millions of Medicaid dollars, and their maneuvering puts independent pharmacies out of business as the big chains, allies to the PBMs, corner the market.

Add insurance companies into the mergers of the PBMs and the huge pharmacy chains, and what is the result? Corporate, healthcare-providing behemoths — vertically integrated and aligned organisms that will crush the last of the smaller, independent competition.

When the interests of the prescriber, the authorizing party, the referring party, a third-party payer and the payee are all aligned, what happens?

The prescribing party over-prescribes. The authorizing party over-authorizes. The referring party over-refers.

Revenues from the public purse will go up, up, up. Either taxes or debt will have to go up, up, up as a consequence.

And when the expertise of the practitioners is in decline, costly blunders multiply. The question will no longer be, “Can you keep your doctor?” but “Can you even find a properly trained doctor?”

And when costly blunders multiply and bad outcomes proliferate, litigiousness increases.

It won’t be long before an abused public will see American healthcare in the same way that its sees Congress and the mass media.

Given that the public trusts the small and the independent more than the big corporations, does any of this make sense?

The incongruous Section 5, which will work against the rest of this latest executive order and earlier ones, will prove to be no winner. Its unintended consequences will make losers of us all.

Caren Gallaher is a surgeon in Tennessee and co-founder of Physicians for Patients.

Tags Donald Trump Healthcare reform in the United States Medicare nurse practitioners Pharmacy benefit management physician assistants

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