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patient comes into the ED, the doctor must do appropriate screening tests and treat the patient as an emergency. This explains the dichotomy in thinking between a primary care physician (PCP) and an
ED doctor. A PCP asks, “What is the most likely diagnosis to account for this presentation?” An ED doctor asks, “What is the most life-threatening diagnosis
to account for this problem?” PCPs will tell their patients to take Maalox for heartburn. Because of EMTALA, the
ED doctor must treat the patient as an emergency and do appropriate screening tests. This is likely a CT chest to exclude aortic dissection and pulmonary embolus. When these tests are negative, the ED physician is able to dismiss the patient without committing a felony. Then the ED doctor tells the patient to take Maalox for heartburn. This has fueled an incredible growth in ED CT scans and MRIs. In 1990, the radiologist left at 5 o’clock and was rarely called back in until the next day. Now there are 40 CT scans between 5 p.m. and 8 a.m. in our ED in Sussex County.
Next, state governments put laws in place
ED wait time. The use of CT scanning increases even more as the doctors have to “treat ‘em and street ‘em” in an assembly line fashion or be out of compliance with ED wait time regulation. This is why the ED is the highest-cost place to receive care. The hospitals and the ED doctors
did not ask for EMTALA. They have
to follow the law or be charged with a felony. The ED doctor can no longer act like a primary care physician because of EMTALA. Increasing access to primary care physicians and diverting as much ER to the PCP is the most effective way to control a large portion of the spiraling health care costs.
1997 – Balanced Budget Act. This act capped the funding of residency programs and has contributed to the current physician shortage. Although medical school graduates have increased
years, the number of federally funded residency programs has not. This contributes to the doctor shortage (estimated at > 90,000) in the United States. In 1993, President Bill Clinton’s Health Security Act was proposed and was immediately shot down, which hurt the Democrats in mid-term elections. This was known as Hillarycare in 1993, and the revamped version became Obamacare in 2010.
The Clintons believed that a surplus of doctors and hospitals was the cause of rising health care. They used a health economist’s postulate, Roemer’s Law, stating that supply induced demand. By having fewer hospitals and doctors, health care costs would be lower. 6,7
They believed this premise by misinterpreting data from the Dartmouth Health Atlas. The Dartmouth Health Atlas uses Health Referral Regions and compares the health care costs between these regions. They compared Medicare costs in Grand Junction, Colorado to the costs in Manhattan. The costs in New Grand Junction, Colorado. Since the per capita income in Manhattan is similar to the per capita income in Grand Junction, the Dartmouth pundits concluded
that this discrepancy was unrelated to socioeconomic factors like poverty. Since there were more hospitals and doctors
in Manhattan per capita than in Grand Junction, Colorado, the conclusion was reached that an oversupply of doctors and hospitals was the cause of the problem. Richard “Buz” Cooper wrote a 2016 book called Poverty and the Myths of Health Care Reform. In this book, Dr. Cooper and compares hospital admissions to per capita income by ZIP code. He elegantly proves that the cause of this discrepancy Grand Junction, Colorado is poverty.8
Intended consequences: Cap the number of trained physicians to limit the spiraling cost of health care.
Unintended consequences:
Create a severe doctor shortage that has fueled the upward spiral of health care costs. Fewer doctors mean greater ED utilization. This shifts care from the low- cost provider to the high-cost provider. The loss of primary care physicians has fueled the growth of physician assistants and nurse practitioners. In comparison
to the PCP, the extended caregivers are more likely to use high-cost imaging and send patients to consultants. The average neurologist in America has a 30 day wait for new appointments. The PCP would likely be able to handle the basic neurologic problem and the extended caregiver will rely on the consult. When patients learns there is a 30-day wait, they go to the ED.
2010 – The Affordable Care Act (Obamacare). Implemented in 2014, it increased health insurance coverage through greater Medicaid coverage and the insurance marketplace. Markets had to accept all applicants regardless of preexisting conditions. All companies having greater than 50 full-time employees had to provide health care coverage.9
Intended consequences:
Increased the number of insured and decreased the uninsured from 16 percent in 2010 to 8 percent in 2016. This was almost all Medicaid patients.
Unintended consequences:
Greatly increased health care premiums for companies paying for employees
and individuals buying insurance. My Highmark insurance premium rates rose from $1,450 per month for a family of three in 2014 to $2,350 per month in 2017. This health cost burden on companies
led to diminished economic growth
and investment in the Obama years. Companies relied on part-time help to avoid the mandate. There was suppressed wage growth since the money that would have gone to increase workers’ pay had
to be spent on high health insurance premiums that then funded the health care
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