Changes and challenges

I have recently been thinking about the many changes in the practice of medicine, both big and small, that have occurred during the last few decades and I’ve come up with quite a list. This list can be subdivided into legislative federal policy changes, development of new administrative tools and technologic advances, including drugs and devices.

I don’t expect to have thought of them all and I’m equally sure there will be many readers who disagree with the level of importance I’ve assigned them, but I’ve found it a useful exercise at this time in my own professional life to try and review the most important advances that have been occurred during my medical career as well as their impact on the practice of medicine.

At the same time, the more I’ve thought about these items, I also have realized how dissatisfied I have become with the effectiveness of our elected leadership and how they seem more focused on arguing, delaying, obfuscating and generally confusing the electorate than they are in actually working for their constituents. If our representatives would work together on the many important issues that impact access and delivery of healthcare as well as the ability of physicians to practice high quality medicine in an unimpeded fashion utilizing the many tools, techniques and technologies that have been recently developed then we physicians could provide better care for our patients. The first part of this discussion will deal with some of the most important federal policy changes of the past 50 years.

Federal policy changes in healthcare

Medicare - When this first federal policy change occurred, I wasn’t even a physician but I’m including it here because of its importance, size, longevity and expense. As a reminder, it was in July 1965 that President Lyndon Johnson signed into law several amendments to existing Social Security legislation, which established the Social Security Act of 1965. This act established a new type of health insurance, known as Medicare, to provide health insurance coverage to people aged 65 and older with the goal of increasing the availability of affordable health care for the elderly. 

Much like the discussions playing out today in newspapers and on television about the Affordable Care Act (ACA), various politicians predicted that Medicare “wasn’t going to work” (Sen. Bob Dole), that it represented “socialized medicine” (George H.W. Bush), that it “took away our personal freedom, would complicate the delivery of healthcare and end the doctor-patient relationship as we know it (Ronald Reagan)."

While I am not sufficiently knowledgeable about all of the economic and social factors regarding Medicare, I believe that during the nearly 50 years since Medicare was introduced, it hasn’t turned out to be the intrusive program that it was initially projected to be and that the doctor-patient relationship does not seem to have suffered irreparable harm from it.  Furthermore, while this program certainly remains confusing and frustrating to many seniors and their physicians, especially when new programs are added (for example, Medicare Part D), the sheer number of people enrolled in Medicare today can certainly be viewed as one measure of its acceptance and success.

HIPAA (Health Insurance Portability and Accountability Act) - In 1996, this law was passed to ensure that people who were covered under one group health insurance plan would still be able to purchase new health insurance coverage should their employment status change without being restricted by either by pre-existing conditions or other long-term health conditions. This law also created certain standards to prevent improper use of medical records and to maintain the privacy of all patients’ personal health information. While the implementation of HIPAA came with a significant number of new requirements, I believe that it has proven helpful to people who change jobs and suffer from pre-existing conditions to obtain health insurance in their new jobs and also helped to secure the privacy of patients’ medical information.

Affordable Care Act (ACA) - More recently, the ACA represents the most comprehensive revision to American healthcare financing. However, it is encumbered with myriad tedious governmental regulations, mandates, conditions and restrictions that will produce dramatic changes (many of which still remain unknown) in the delivery of healthcare once all of its provisions have been fully implemented. 

Some of the main provisions of ACA include: a mandate that requires all individuals to have health insurance coverage or face financial penalties, makes eligibility changes in Medicaid to expand coverage, guarantees availability of health insurance coverage to all citizens of the United States by providing cost-sharing subsidies for those with incomes up to 250 percent of poverty level, imposes fees on employers with over 50 employees who do not offer medical insurance coverage, establishes state health insurance exchanges, prohibits annual coverage limits and establishes a physician payment system which is tied to the quality of care provided. 

At the time of this writing, there remain many unanswered questions about this new program. In addition, online enrollment has proven frustrating, time-consuming and difficult, which has added to the concern of the American public about how well this new program will function when its provisions are fully rolled out. The ultimate acceptance of the provisions of ACA as well as the cost and likelihood of success for this program will require careful scrutiny for years to come. The effect on the patient-physician relationship has also yet to be determined.