Eyeworld

EW NEWS & OPINION 26 October 2016 Insights by J.C. Noreika, MD, MBA Finally, I asked how physicians might command greater influence in fixing the system. He said that doc- tors are often not knowledgeable in the nuances of health care reform. Like most constituents, doctors can readily enumerate their complaints but offer little in the way of solu- tions. To persuade an elected official, it is useful to offer a constructive alternative, taking into account the wants and needs of constituents other than one's own. Elected officials know phy- sicians are smart. We wield more power than we think; we have access and can be heard. What we need is an effective message crafted as a solution extending beyond our personal financial concerns. There is much furrowed ground to be sown. If you disagree with the Affordable Care Act, oppose future expansion of Medicare, fume at the unrealistically low reimbursement of Medicaid, think MACRA, MIPS and Alternative Payment Models abominations, and allege that the EHR qualifies as Dante's tenth circle of Hell, analyze why you hold these assumptions and then prepare by expending time and initiative to participate in the game. The Senator will listen and may even buy lunch. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio since 1983. He has been a member of ASCRS for 35 years. Contact information Noreika: JCNMD@aol.com rise of Accountable Care Organiza- tions (ACOs). It is unclear whether ACOs will produce better quality at lower cost. A recent editorial in Forbes magazine indicated that "16 out of 23 (ACOs) are financially busted and six more are on the verge of collapse." When I suggested that the subversion of the small, com- munity-based medical practice is not in the best interest of patients, he agreed and then said something interesting: Health care is simply following the lead of other Ameri- can industries and professions. The banking industry was cited but other examples abound. Consolidation into ever-larger organizations began before the Affordable Care Act. It may be capitalism's inevitable des- tiny. He implied it's important that physicians recognize this existential trend and prepare to guide it. I asked how might an influential Democrat fix the Affordable Care Act. Not surprisingly, he cited the President's expansion of a "public option" to stabilize the volatility in the insurance markets. For example, any citizen could select Medicare as an alternative to a plan purchased from a private insurer on the ex- change. During his campaign, Bernie Sanders promoted this. My friend instantly admitted factions opposing further expansion of federal bureau- cracy that exert increased power and greater centralized control would passionately resist such policy. But he mentioned that Hillary Clinton has proposed Medicare be extended to those over 55. were not addressed after its passage is, ironically, President Obama. The act's passage was one of the most partisan and contentious in the history of Congress. Those Repub- licans who were shut out at its creation became intransigent when it required later change. According to the senator, Democrats offered more than 200 amendments over the years. Many in the opposition pushed for the act's outright repeal. The waters were poisoned; neither option can transpire until President Obama leaves office. One of the sacred tenets of salesmanship is to underpromise and overperform. I noted that the President boldly overpromised by announcing if you liked your doctor and insurance plan, you could keep your doctor and insurance plan and that the price of your premium would decrease. The Senator said it was the only way the law could have gotten done. I was both surprised and chagrined by my naiveté when he said that the practice of politics implies voters expect all successfully elected officials to overpromise. This contrasts sharply with medicine's customary ethic. Imagine telling a cataract patient with a damaged macula that a novel lens implant will unquestionably provide 20/15 vision without glasses at no addi- tional expense. We discussed the consolidation of medicine as insurance companies and hospitals merge or acquire to buy market share, afford expensive IT systems and achieve theoretical economies-of-scale. I spoke to the Lunch with an influential U.S. Senator provides an opportunity to listen, learn, and be heard A pundit recently posted a pie chart on Facebook. Green represented the segment of friends whose political leanings would change after reading your erudite post supporting a favored candi- date. Blue showed those friends who would not be swayed by your well-reasoned logic. Red depicted the percentage of friends who would only be peeved by your fair and bal- anced favoritism and then unfriend you. The pie chart's circle was entire- ly red. With this in mind, I report the following with trepidation. According to one recent federal survey, the percentage of uninsured is 8.6% or 27.3 million people, down from 9.1% in 2015 and at a histori- cal low. But many of the uninsured are young adults, mostly male and poor, whose purchase of health insurance is necessary to prevent the Affordable Care Act's so-called "death spiral" as more older, acutely ill patients join the exchange's insur- ance plans. This has led to higher premiums, $11,000 deductibles for a family of four's Bronze plan and prohibitive co-pays. Major insurers like Aetna, Anthem, Humana, and UnitedHealth Group have exit- ed many exchanges. If you are a Democrat, you refer to these issues as remediable challenges. If you are Republican, you see them as failures of Obamacare redressed by starting over. In September, I sat down to lunch with a U.S. Senator who thinks the Affordable Care Act, a program directly impacting almost 20% of the nation's economy, can be saved. Knowing him for 25 years, the man is highly intelligent, hardworking, honorable, thoughtful and listens. He has been a friend to ASCRS and ophthalmology. He said that a critical reason the shortcomings of Obamacare Playing the game J.C. Noreika, MD, MBA

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