Three Changes I've Seen from Obamacare

In this year of political debate and presidential campaigning, one popular topic of discussion is healthcare reform. Did Obamacare make things better or worse? Have the promises of the Affordable Care Act been realized? What lessons have been learned and how will this influence the future dialogue and legislation?

This is part one of the top six changes I have seen over the last few years related to Obamacare. Without a doubt, not all of these (good and bad) changes can be laid at the feet of healthcare legislation, but the ACA has definitely contributed, at least in part, to each of them.

1. Patients who should be seen in the ED scheduled for a 15 minute office visit. It is no longer unusual for me to evaluate new-onset chest pain, stroke symptoms, or severe abdominal pain in a 15 or 20 minute acute visit. When a patient calls with certain symptoms, our nursing staff will advise they go to the emergency room for conditions that could be serious or life-threatening. However, with $200 co-pays to the ED or for a patient with a high deductible, the emergency department is avoided at all cost. Unfortunately, I still see patients routinely going to the emergency department during office hours for conditions that could be appropriately treated in the office. We have yet to align our systems and reimbursement to get the patients to the right level of acuity care.

2. The patient has become the customer.  When I was in medical training as a student and resident, I was taught many things about how to interact with my patients. They deserved my respect, which I showed by shaking a hand, performing exams in the least intrusive way possible, looking for signs of fear, worry, or pain, and by being honest. I was never taught customer service or how to please a patient. Some patients were happy no matter what I did, while others were unhappy no matter what I did. We all seemed to accept that being a physician was a profession, a calling, and as such, the motivation for treating patients with respect was that it reflected the dedication we felt towards our fellow human beings. Nowadays, instead of modeling my patient care on that described by Sir William Osler or one of my wizened and experienced attending physicians, I think about Disney or the Ritz-Carlton. Am I smiling? Did I remember to shake a hand (or did I stop myself from shaking a hand if the patient doesn’t like it)? Is the customer happy?

3. Patient continuity has become dangerously fractured. When I still did full-spectrum family medicine, I followed my patient from the office to the hospital to the nursing home back to their home. While it was not a perfect system, the primary-care physician acted as a navigator and provided oversight of the patient’s medical journey. Now that we have ambulatory care specialists, hospitalists, specialists, intensivists, and nursing home specialists, patients are handed off from physician to physician with little consistency from the team members and sometimes poor communication as they transition. The more medically complex and sick a patient is, the more hand-offs they experience, and the higher their risk of having something missed along the line.

My next blog will continue this list and focus on pay-for-performance, payment reform, and the EHR.