In time of change, the physician must remain the advocate of the patient

Richard L. Lindstrom

As I age, like most of those approaching or at Medicare eligibility age, I find myself requiring more health care.

I remember asking a former dean of the University of Minnesota Medical School, whose cataract surgery and glaucoma I managed, his impressions of medical care as a patient. He stated that compared with a younger age, he had many more physicians participating in his care and he knew them much better. He highly valued access to the physicians, surgeons and health care facilities of his choice, and he desired compassionate, quality care at a reasonable and fair cost. Basically, he wanted free choice as to provider and a good value, much the same as in any other purchase. And he felt he was in a position to judge whether he was receiving quality, compassionate, cost-effective care better than any other third party.

These are the key issues we and our elected representatives (because federal and state government now pays for more than 50% of health care in America, and more in some other countries) are struggling to manage: access, quality and cost.

I remain convinced that the primary patient advocate is the physician. In which, in the case of the ophthalmologist, we commit one person at a time to do all we can to help each human being that entrusts their care to us to dedicate our best efforts to preserve, restore and when possible enhance their vision — an awesome responsibility, requiring decades of training, lifelong continuing education, long hours, hard work and good people skills.

Fulfilling this sacred covenant in the practice of medicine becomes more difficult every year. I believe it is because governments and employers promise their citizens and employees access to the highest quality medical care at little or no cost. Clearly, this is a worthy goal, but the unfortunate fact is the cost of universal health care of the highest quality is expensive and arguably impossible to finance by even the richest country. To support the costs, the federal government can tax, borrow or print money. State government can only tax and borrow.

If the economy is healthy, growing rapidly and there is a large, fully employed and growing work force to tax, the escalating costs of the social welfare benefits governments love to promise their citizens remain affordable. Thus we have the BRICK countries, which include Brazil, Russia, India, China and Korea. These countries, most of which have a relatively meager social benefit commitment to their citizens, are magnates for capital investment and show GDP growth that sustains and supports increasing government costs. On the other side of the coin, we have the so-called PIGS, including Portugal, Italy, Ireland, Greece and Spain, where the governments’ social contract with their citizens can only be sustained through excessive borrowing, monetary inflation and increasing taxation. Unfortunately, eventually the taxes rise high enough that they can no longer be raised any further without revolt, and borrowing costs reach levels that are, by any standard, usurious. In Greece today, 2-year notes demand 26% interest.

In America, in my opinion, we are transitioning from the most solid of BRICK countries to the king of the PIGS. Imagine a U.S. economy with combined federal and state taxes in the 80% range, 10-year treasuries at 15%+, pegging mortgages at 16% to 18%, discretionary loans such as for automobiles and the like higher than 20%, and credit card debt at 30%. Such is the future we are facing unless our federal and state governments’ spending patterns change.

Today, that pattern encompasses Social Security, health care including Medicare and Medicaid, defense and the ever-growing interest on the national debt. Each of these areas of government spending must and will be “rationalized” to our government’s ability to pay, or in a decade or two we will be experiencing the trauma of Greece today.

For the ophthalmologist in America, in general living quite comfortably today, our country’s battle to deal with these fiscal realities will require significant thoughtful business and personal planning and likely some adjustments in lifestyle expectations. How does this all relate to the heath care reform alphabet of accountable care organization (ACO), sustainable growth rate (SGR) and independent payment advisory board (IPAB) and the plan to add 32 million uninsured Americans to the states’ Medicaid roles? Each of these will present challenges for at least some ophthalmologists.

ACOs to me look like, sound like and quack like a health maintenance organization (HMO) with, in most cases, large hospital holding companies in control. My definition of an HMO’s purpose is “interference in the practice of medicine for a profit,” at the expense of both the patient and the doctor. The purpose of the ACO will be the same, to manage access and cost of care in the same fashion that HMOs did in the past while generating profits for the ACO. The providers will be put at risk for the access and cost of care and will be pressured to reduce both. In the end, I expect most ACOs, like the HMOs that preceded them, will fail to materially reduce costs, and they certainly will not enhance quality. In areas where hospital-directed ACOs have a powerful monopoly, ophthalmologists will need to proactively seek to be participating providers in the physician panels, or they risk being denied access to a large number of patients.

Meanwhile, the SGR will likely trigger a continuing below inflation adjustment in Medicare physician fees. Ophthalmology has fared well the past 2 years thanks to the timely advocacy of our leading ophthalmology societies, but I suspect another round of fee reductions is coming, considering the dismal economic outlook and unsustainable growth of medical costs, now approaching $2.4 trillion, 20% of GDP and growing at 6% per year when our economy is growing only at 2% per year. We baby boomers gaining Medicare eligibility at the rate of 10,000 people per day will only exacerbate the problem. Plan on lower fees from Medicare per unit of care. In addition, the IPAB can only be expected to reduce cost and access to reign in accelerating government deficits in the years to come.

Top priorities for us include a permanent fix for the SGR and elimination of the IPAB. Support the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery with PAC contributions, as they are working hard for you politically to modify or eliminate these potentially destructive programs. Finally, we will all need to prepare for a significant increase in the Medicaid population seeking our care if the current version of heath care reform is not rescinded by a new Congress.

Our practice loses money on nearly every encounter with a Medicaid patient, and reimbursement in our state is superior to many. It is likely that as more physicians choose to limit the access of Medicaid patients to their offices, state legislatures will respond by requiring open access in our practices for these patients as a requirement to maintain state licensure to practice. In the end, it will be impossible for the government or our business and government employers to provide in a defined benefit plan like today’s Medicare open access to the highest quality care that our best trained and equipped physicians, surgeons and institutions have to offer.

The ultimate solution, in my opinion, is a shift away from the current defined benefit plans to defined contribution plans with increasing patient-shared responsibility for the costs of care. Patients will be given the equivalent of a voucher worth a certain fixed number of dollars toward each examination or procedure. Physicians and surgeons will be free to charge an incremental fee for the costs above the amount the third-party payer can afford to contribute. The patient will increasingly share the responsibility for the costs of his or her health care. This is the only solution that is sustainable and retains patient freedom of choice and access to the best technology and compassionate quality care that each of us want for ourselves and our family.

It will be my generation of baby boomers that will need to navigate the minefields to a sustainable and socially fair defined contribution plan with increased patient-shared responsibility for health care costs and appropriate safety nets for the truly poor and indigent.

We physicians will need to bear the responsibility to advocate not only for ourselves but also for our patients. It is absolutely critical that we physicians engage in the political process, as the proposed solutions will come from our elected representatives. We physicians know our patients’ needs better than anyone else, we know what access to quality care really means, and we know how to provide it in the most compassionate and cost-effective fashion. We must make sure our voices are heard, or else our society, our profession and our patients will suffer greatly.

• Disclosure: Dr. Lindstrom provides practice management or marketing consulting services to 3D Vision Systems, Abbott Medical Optics, AcuFocus, Adoptics, Advanced Refractive Technologies, Alcon Laboratories, Aquesys, Bausch + Lomb, Biosyntrix, Bradley Scott Inc., Calhoun Vision, Clarity Ophthalmics, Clear Sight, Glaukos Corporation, High Performance Optics, Hoya Surgical Optics, LenSx, Ocular Surgery News/SLACK Incorporated, TearLabs Inc. and TLC Vision Corporation.