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Docs: Running to Stand Still

Wednesday, August 4, 2010

Primary care doctors have complained for years that they feel like hamsters on a treadmill. Under new rules just issued as part of ObamaCare, the treadmill kicks into higher gear.

The Obama administration recently issued interim final rules to implement the preventive care mandates of the major healthcare legislation passed in March. The promise of preventive care—particularly when offered for “free”—is a superficially popular feature of the new law. At least until inflated demand collides with more limited supply.

The new law, the Patient Protection and Affordable Care Act, requires many group health plans (except those with “grandfathered” exemptions) and private health insurers to cover a lengthy list of recommended preventive care services without imposing any cost-sharing obligations on the patients who receive them. Other provisions of the law also expand Medicare and Medicaid coverage of preventive care.

The general popularity of widespread preventive care rests on the shaky presumption that such medical services head off more serious medical conditions, save lives, and reduce healthcare costs.

The general popularity of widespread preventive care rests on the shaky presumption that such medical services head off more serious medical conditions, save lives, and reduce healthcare costs. A lengthy literature actually challenges each of those premises; at least when recommended preventive care services are not limited to a shorter list of medical interventions and targeted to the most appropriate types of patients likely to benefit from them. But the broader political argument often is that “cost” should not be a disincentive to greater demand for such presumably necessary services, particularly when society as a whole is supposed to benefit in the long run from better population health.

Let’s leave aside for the moment the demand side of this debate, as well as predictable problems of overuse of screening, false positives, medical side effects, and intensified lobbying to make the list of required services. The new law’s edicts also are guaranteed to outstrip available supply. Just because Congress and the administration have tried to insist that someone else (employers, insurers, individual premium payers, healthcare providers) must absorb the hidden pass-through costs of additional “free” care, they cannot ensure that those services actually can be delivered in the volume and manner prescribed by law.

The new law’s edicts also are guaranteed to outstrip available supply.

Several notable studies of the supply side of preventive care suggest how ObamaCare, as the healthcare legislation is often known, plans to make a difficult situation impossible. In 2003, a team of Duke University researchers first estimated the amount of time required for a primary care physician to provide then-recommended preventive services to an average patient panel. In a study published in the American Journal of Public Health (“Primary Care: Is There Enough Time for Prevention?”), Dr. Kimberly Yarnall and colleagues conservatively calculated that a primary care physician would need to devote 1,773 hours of annual working time (7.4 hours per working day) to provide and fully satisfy all the preventive services recommended by the U.S. Preventive Services Task Force. They concluded that the preventive services recommended for the U.S. population back then simply required an unreasonable amount of physician time. The authors emphasized that the large number of screening recommendations for each patient, coupled with the large numbers of patients in a practice, were likely a major reason for the failure to provide these services.

In 2008, a similar team of Duke researchers, led by Kathryn Pollak, examined in a BMC Health Services Research study the estimated time spent on preventive services by primary care physicians. They concluded that, with the current physician shortage, doctors will likely be able to do less—not more—in preventive services. A more realistic interim solution was to help physicians prioritize preventive care that they themselves can provide best and to delegate services that other members of the healthcare team can provide.

Primary care doctors have complained for years that they feel like hamsters on a treadmill, because they must run faster in seeing more patients for shorter times just to stand still.

Since the time of the aforementioned estimates, the list of current and likely future recommended preventive services (soon to be “free”) has only grown longer, while the supply of primary care physicians and other medical practitioners is more and more overstretched. Primary care doctors in particular already have complained for years that they feel like hamsters on a treadmill, because they must run faster in seeing more patients for shorter times just to stand still.

As with other mismatches between what the new health law commands and imagines, and what everyone else can actually manage to handle or needs, a different approach is urgently needed—one based on different priorities, decentralized tradeoffs, deregulation of healthcare delivery options, patient responsibility, and common sense. But the core premise of ObamaCare remains that political demand can magically create greater supply—without even having to pay (or charge) for most of it. The ambition appears to be to outdo the apocryphal tale of King Canute, Viking ruler of Denmark and England in the 11th century, who once commanded that his royal chair be brought down to the water’s edge of the ocean and then ordered the waves to stop rolling. President Obama and his top advisors actually have assumed that they can make the waves of healthcare supply and demand stop at their command.

Thomas Miller is a resident fellow at the American Enterprise Institute.

FURTHER READING: Miller also wrote, “The Morning After: Waking up with a Coyote Ugly Healthcare Bill,” “Should We Fight Today’s War on Obesity Like the Last War on Tobacco?” and “Healthcare Dreams, Healthcare Realities.” He discusses “How to Cover Preexisting Conditions,” “Changing the Name—but Not the Political Game” with James Capretta, and “Health Reform’s Late-Term Delivery: Struggling with Political Birth Defects.”

Image by Darren Wamboldt/Bergman Group.

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