Where are Obama and Obamacare Headed?

Posted by Stephen E Weinberg, MD FACC FACP
I believe President Obama made his feelings known during the 2008 Presidential campaign. He stated over and over that he felt physicians should be salaried and there should be an end to fee for service medical care. He believed then and now that the fee for service system breeds increased costs by incentivizing physicians to order more tests and procedures. He stated in a July, 2009 press conference: “You come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”

The implication was that a pediatrician would decide to remove the tonsils of his patient (which could never occur) or that there was some kickback from the surgeon to the pediatrician (which would not occur). Additional references have often been made about the overuse of CAT scans and MRI’s as well as other imaging procedures by general practitioners is as a result of financial gain. They do not own or receive payments from imaging centers. It is clear that the President sees a large part of the medical system as one large conspiracy of kickbacks and self-interest. Many members of Congress have stated similar opinions.

As a result of this conspiracy theory, the President would like to see all physicians in salaried roles similar to the Mayo Clinic and Cleveland Clinic. He believes this would solve our healthcare economic problems by reducing costs. There really is no data to show that this is the case.

In fact, Medicare performed several studies and demonstration projects in the past 10 years to try to prove that incentivizing hospitals and large group practices to create plans to reduce costs would actually be effective.  The CBO, in 2012, evaluated these studies and found that one project involving cardiac bypass surgery did save about 10% over standard care, but the other 3 studies showed no financial benefit, including the 10 group study of about 6,000 salaried physicians. A Feb. 26, 2014 study in JAMA involving 32 practices in Pennsylvania demonstrated no quality improvement or cost savings over 3 years involving the Medical Home concept which has been touted to be the best model for primary care. In an accompanying editorial, the Dean of the University of Nevada School of Medicine pointed out that often things which appear obviously true do not stand up to scientific scrutiny.

So where does this leave us? President Obama is creating a situation where he is pushing physicians into salaried positions with his Medicare reimbursement policies (more about that later) based upon his assumption that this will reduce costs and improve quality of care without any evidence that this is so. He is willing to dismantle the entire healthcare system in the absence of knowing what the end result will be.