SEP 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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Page 37 of 103

38 EW NEWS & OPINION September 2012 An unintended consequence Insights by J.C. Noreika, M.D. P araphrasing Gertrude Stein, the United States Supreme Court ruled that a tax is a tax is a tax, upholding the universal mandate and, thus, the Patient Pro- tection and Affordable Care Act of 2010. The signature piece of legisla- tion of my generation, it realizes a political vision first espoused by Theodore Roosevelt in 1912. A massive sector of the nation's economy, healthcare is an industry of hospitals, insurance and pharma- ceutical companies, durable goods manufacturers, nursing homes, and medical professionals. At any given time, 50 million inhabitants of the U.S. find themselves outside of the quasi-system. This group increases during times of rising unemploy- ment and accretive immigration, legal or otherwise. Young, healthy adults forego insurance for goods and services of greater perceived value and gratification. Since 1965, Medicare for the late middle-aged and elderly has contrasted health in- surance's demographic accessibility in bold relief. The role of private insurance for local, state, federal, union, and business employees has been affirmed by granting tax privi- lege and, now, exemption from the new law's more onerous mandates. Medicaid, provisioned by federal and state government, is the safety net of the lowest economic quartile of citizenry, especially children. Medicaid will prove the Achilles' heel of the Affordable Care Act if the price of its massive expansion is not addressed. According to the Wall Street Journal, the federal govern- ment currently spends $400 million per hour. The new law will increase this amount. The fog of revolution obscures a likely consequence. Well-educated policymakers in impenetrable bureaucracies like the Department of Health and Human Services have decreed that medicine's cottage industry is too prosaic for the impending explosion of demand. Indeed, the industrialization of family practice is nearly complete; it is the rare general practitioner who toils independently of a delivery system that is itself the likely consol- idation of smaller, local hospitals. Anticipating enhanced demand for healthcare services induced by the Affordable Care Act, the federal government has encouraged the de- velopment of the accountable care organization (ACO). There are 65 such experiments nationwide. Variations of this concept owe their lineage to Henry J. Kaiser's health insurance invention created during the wage-capped days of World War II. Kaiser Permanente remains the country's largest and, arguably, most influential private healthcare model. Other experiments such as the med- ical home are being studied. Many are fashioned on past innovations like the health maintenance organi- zation (HMO) and its kin, the inde- pendent practice association (IPA). Prescribed as the anodyne for the fee-for-service system, they seek efficiencies by sharing economic risk. Even in highly penetrated states like California, cost savings have disappointed. If the architects of this brave new world of medicine were to audit my clinic, they would conclude our nation cannot afford the gratifica- tion of its citizens' perceived need. The troika of advanced—read: expensive—medical technology, the lack of personal responsibility for one's health regarding body weight, diet, sedentary lifestyle, and risky behavior, and the willingness of elected officials to obfuscate result- ant cost to society demand a sober- ing recalculation of expectation. I am not a romantic. Some physicians may be better served by working for large integrated hospital systems that manage the business of healthcare, implement and oversee advanced technology and informa- tion systems, better align a patient's needs with available resources, and provide equitable compensation. This model can work well for newly minted Gen X and Gen Y doctors, many of whom are female. Interest in residency programs that offer predictable work hours is high. The promise of a lifestyle balancing career, family, and home compares favorably to a career that Dr. William Osler described as the "jealous mistress." In healthcare organizations, the practice of medicine can be a job, and therein lies the concern. Most doctors commit to a career that promises years of training, continual education, long hours that often extend beyond the 40-hour week, and phone calls in the middle of the night. The very best of the best, a doctor's doctor, embraces medicine as inextricably entwined with the ancient calling of priestly vocation. Medicine's implicit humanism and challenge of scientific progress will continue to attract the best and brightest. It offers a tangible, imme- diate opportunity to make a differ- ence. The government's approach to reform is a secular initiative. It may mandate access to healthcare but cannot guarantee the best medicine. In the thousands of pages of the Affordable Care Act, there is no assurance that the physician's higher calling will survive the revolution, a most unfortunate unintended consequence. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com

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