Page 23 - Delaware Medical Journal - May/June 2018

TRANSFORMATION IN HEALTH CARE
of patients with preexisting conditions and commercial Medicaid patients. Since the newly insured through Obamacare are almost all Medicaid patients and there is a clear relationship between poverty and health care utilization, the cause of the rising cost of health care to the state is
an unavoidable consequence of Medicaid expansion in Delaware.
What can we do?
The obvious answer is to increase the number of independent primary care physicians in Delaware. Delaware primary care physicians are paid approximately 80 percent of Medicare rates by commercial insurers. In other states, primary care physicians get approximately 120 percent of Medicare rates. Delaware was ranked as number 49 in primary care salary
by state.10,11 With this pay discrepancy, our primary care physicians will retire, relocate, become employed, or open a concierge practice. The situation is even worse for psychiatrists. The absence of adequate primary care and psychiatrist reimbursement produces an outpatient care shortage that leads to high-cost ED utilization.
Medicaid patients must have incentives to see or at least contact a primary care physician before going to the ED in non-911 situations. Clinically integrated networks of independent outpatient physicians must be built to identify the Medicaid patients who are the highest
REFERENCES:
1. Altman, D, Frist, WH. Medicare and Medicaid at 50 Years: Perspectives of Beneficiaries, Health Care Professionals and Institutions, and Policy Makers. JAMA. 2015; 314 (4): 384–95.
2. Dorsey, JL. The Health Maintenance Organization Act of 1973 (P.L. 93- 222) and Prepaid Group Practice Plan. Medical Care. 1975; Vol. 13, No. 1: 1-9.
3. Kongstvedt, PR. The Managed Health Care Handbook. 4th ed. Aspen Publishers, Inc.; 2001: 40.
4. Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA): What It Is and What It Means for Physicians. Proceedings (Baylor University Medical Center). 2001; 14(4): 339-346.
5. Zuabi N, Weiss LD, Langdorf MI. Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements. Western Journal of Emergency Medicine.
in reforming health care delivery, and they seem to be left out. When patients do not have to pay or pay much less than the cost of a service, there is no incentive for the patient to contain costs.
Americans have produced a culture

Everything should be available 24/7. The internet never closes. ATMs are always open. Long gone are the days of banker’s hours and a 9-to-5 lifestyle. No one can miss work to see a doctor, so the patients go to walk-in clinics and EDs after work. They use the more convenient, higher- cost setting instead of the PCP. This
trend will continue because ED care is fast and accurate, high tech imaging is used immediately, and the patients get grown to demand. This is a patient-driven phenomenon.
This abridged history of medicine shows that transformation of health care is an ongoing, never ending process. How will this latest transformation differ from others? Will we solve problems or make more problems? I encourage you to read on and form your own opinion.
CONTRIBUTING AUTHOR
■ ANDREW DAHLKE, MD is a Neuroradiologist working in Lewes, Delaware and currently serves as President-Elect of the Medical Society of Delaware.
utilizers of medical services. Aggressive outpatient interventions must work continuously with these patients to
keep them out of the ED. They must know whom to call if they have a problem. These are patients with chronic such as home oxygen therapy, diabetes, chronic congestive heart failure, dialysis- dependent renal failure, COPD, and morbid obesity.

improved education and economic growth is necessary to rein in the cost of health care. We need to provide more education high-risk behavior with high morbidity and mortality. These areas include obesity, drug and alcohol abuse, gun violence, and sexually transmitted diseases.
People compare the total cost of care
in the United States to other countries like France and Sweden. The total cost of health care is much higher in the
U.S. When you add together the amount of money spent on health care and
social programs to help the poor, the amount spent in each country is similar. Poverty produces a lifestyle that leads to excessive medical care utilization.
The primary focus of the transformations in this abridged history is on the actions of doctors, the government, and the insurers. The patients are the most important factor
2016;17(3):245-251. doi:10.5811/westjem.2016.3.29705.
6. Schneeweiss, R, Rosenblatt, RA, Dovey, S; Hart, LG, Chen, FM, Casey, S, Fryer, GE Jr. The Effects of the 1997 Balanced Budget Act on Family Practice Residency Training Programs. Fam Med. 2003;35(2):93-9.
7. Salsberg, E, Rockey, PH, Rivers, KL, et al, Brotherton, SE, Jackson, GR. US Residency Training Before and After the 1997 Balanced Budget Act, JAMA. 2008;300(10):1174-1180.
8. Cooper, R. Poverty and the Myths of Health Care Reform, Johns Hopkins University Press; 2016.
9. Blumenthal, D, Abrams, M, Nuzum, R. The Affordable Care Act at 5 Years, NEJM. 2015;372:2451-2458.
10. Sahadi, J. Doctors Here Make $472,000, CNNMoney, January 27, 2016.
11. Doximity First Annual Physician Compensation Report, April 2017. https://s3.amazonaws.com/s3.doximity.com/careers/2017_physician_ compensation_report.pdf.
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