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Expanding access to healthcare and reducing cost


USA 7 September 2013 Obamacare is based on the proposition that it is possible to expand access to health care and reduce the cost of care without compromising quality or denying service. There are four defects buried in that proposition giving it as much chance of enduring as a juggler has of safely keeping four running chain saws in the air simultaneously.



The first defect in Obamacare is that expanded access to care is not assured by federal mandate because individual physicians cannot be forced to provide access to new patients. One very important reason for individual physicians denying access to new patients is that reimbursement from government programs and private insurers is below the cost of providing care. Does the federal government force WalMart to accept $41.99 from a customer for an item that cost the company $52.50 to put on the shelf?



The second defect is that patients who are denied access to care through a physician’s practice end up in a hospital where they must be seen and where the cost of providing care often is greater than in a clinic or private practice. Expanding access to care and reducing its cost are fundamentally at odds because reducing reimbursement does not cut the cost of providing that care. It simply squeezes the health care provider and expects that provider to continue offering care.



Obamacare’s third defect is that expanded access does not assure access to the entire range of health-care services available. Many procedures such as a double lung transplant are so expensive due to the number of highly-trained health care specialists necessary to provide care that even cutting reimbursement to the bone does nothing to reduce the cost of that care. Under Obamacare expensive care will be denied selectively to senior citizens because their life expectancy is not long enough to fully pay for that care from their taxes.      



The fourth defect is that expanded access does not assure access to quality care. Increasingly, private patients are being seen by nurse practitioners rather than by physicians, thereby reducing the cost of seeing that patient because nurse practitioners are not as well paid as physicians. The compromise to care derives from the fact that nurse practitioners do not have the specialized training that physicians are required to have in order to become board certified. Would you rather have the airliner you’re flying on cleared by a master mechanic or an apprentice?  



To address the quality issue, there is a strong movement in health care toward “evidence-based medicine.” EBM has evolved from clinical epidemiology in which health care treatment is based on the current best evidence regarding the treatments that work.  It is defined as “the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.” The effectiveness of the various treatment regimens available for any given diagnosis is expressed in strict numerical fashion. Simply put, a regimen with an assigned value of 10 is superior to one with a value of 59. Under EBM, the practitioner would be expected to use the treatment with the lower score and conceivably would not be fully reimbursed or reimbursed at all for recommending a treatment with a higher score.



“Evidence-based” is found more than 30 times in the Affordable Care Act. With that kind of emphasis from Obamacare, EBM is bound to become the community standard for care and any practitioner who does not use it or otherwise departs from its strictly internal logic could face serious consequences in a malpractice lawsuit. Or that practitioner may not be board-certified if he/she does not pass the EBM section on the certification exam. Pediatricians preparing for this fall’s board certification exam in child abuse are expected to master EBM essentials.



Since EBM identifies the treatment regimen that works best for any given diagnosis, there is no compelling need to see a physician. A nurse practitioner, perhaps even a registered nurse, will do. Thus the cost of care is reduced without compromising quality provided the patient’s condition has been correctly diagnosed, and the patient matches well to the underlying population sample from which the mathematical estimates have been derived.



Couple EBM with electronic medical records that use the scroll-down-the-page-till-you-find-the-correct-item-to-check system and the future of health care in the United States comes into focus. Welcome to the brave new world of medicine by the numbers.

Edward J. O’Boyle is Senior Research Associate with Mayo Research Institute.

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