There is a scene from the movie Dr. Zhivago that, no matter how often I see it, sends chills down my spine. Yuri returns home from World War I after the communist revolution in Russia and runs into his half brother. Yuri finds that not only has his house has been taken over , but being a doctor, he has been “assigned” to work at a certain hospital. We all know what that means. There is an obvious look of horror on Yuri’s face, but he complies knowing full well what would happen if he didn’t.
Although we are not quite there yet, I have to wonder if that is where we are headed. When the ACA was passed, the modus operandi was first to offer an incentive to participate, and then once providers were in knee deep, pull the incentive away. Think EMR. It was no different with low ACA reimbursements and Medicaid expansion.
Knowing full well that the number of Medicaid participants would explode, the government first offered increased reimbursement for the burgeoning Medicaid population then once providers became dependent pull the incentive away which is where we are now. That’s was how it was supposed to work in theory, and some providers did become stuck, but for the most part it did not work out that way. There is now a struggle to try and prevent a mass exodus form Medicaid. Some states are trying to continue the incentives, for now at least, but some are trying to force providers to make Medicaid acceptance a condition for licensure. Some are trying to set the percentage of a practice that must be Medicaid. If that does not frighten you, it should. In an ideal world, both parties would be free to negotiate a compromise solution but we know full well we are not living in an ideal world.
Years ago, the vast majority of the population would view that scene from Dr. Zhivago and conclude that Yuri is being treated horribly. Today, there a is a growing population that would look upon that scene and conclude that its a great idea. After all, all physicians are rich, and they should be forced to provide what we need. Eventually, a politician will be elected on the basis of this platform, and the “assignments” will begin. The assignments will be minimal at first, but it will not end there. Eventually, the assignments will reach a critical mass where only those providers who are unable to leave will be in practice, knowing full well what would happen if they didn’t comply.
Physicians have been sitting in that proverbial slowly boiling pot of water for some time now with no end in sight. Of all the changes, this one — where the government essentially divorces required work from reimbursement — turns up the heat to its hottest point yet. If this does not push providers over the edge, what will?
Thomas D. Guastavino is an orthopedic surgeon.
Image credit: Shutterstock.com
