I'm Not a Doctor: But ....

 I’m Not a Doctor; but…

Mike DiGiuro

Full disclosure – I am not a doctor, nor have I ever played one on TV; but to me Obamacare, like most government schemes, seems fraught with unintended consequences – or maybe they are intended. 

I have discussed the coming changes in health care that will be the result of Obamacare, with primary care physicians, specialists, and healthcare extenders (Nurse Practitioners and Physicians Assistants) and among these practitioners there seems to be a clear group of winners and a more murky group of losers.

There are lots of people making noise about the coming doctor shortage, caused by suddenly 30 million additional people now having health insurance, and clamoring for treatment.  The obvious course is to fill the void with Nurse Practitioners and Physicians Assistants who very capably handle millions of patients every day.   

These Healthcare Extenders will probably be the big winners in the new health care market.  Many specialists also seem to be poised to win under the new law, while primary care physicians seem destined to lose, and may possible be doomed..

The reasons will revolve around insurance companies attempting to restrain costs, by incentivizing patients to visit lower cost healthcare providers like retail clinics in places like Kroger and Walgreens.  Since the retail clinics are staffed by LPNs and PA’s the cost is less for the insurance company.  Under many insurance plans, a visit to a clinic might well be free, while a visit to a primary care physician will require a co-pay of $20 - $50. 

While this incentivization will obviously negatively impact primary care physicians, it could ultimately eliminate visits to primary care physicians and maximize visits to specialists.

For example, the LPN at a retail clinic has 10 patients with a persistent cough.  The LPN  prescribes something and waits to see what develops.  If the treatment does not “cure” the problem, they will likely refer the patient to a lung specialist.  The primary physician might have several other options for a patient, but the LPN in the clinic really has few.  If they can’t solve the problem, they generally refer the patient to a specialist.  What they will not do is refer their primary care patient to a primary care physician.  Why would they send their patient to a competitor?  If they go to the specialists, they come back for routine stuff to the retail clinic.  If referred to a physician, they may stay there for routine matters.


The end result will be more and more patients referred to specialists, and longer and longer wait time to see the specialists.  While there will be no official “rationing” of care, the result is the same: long wait times.

There will then develop a “expedited” appointment scheme where primary care physicians, working for their patients, will use the old boy network to get their patients quicker appointments and therefore short cut the lines.  So paying a co-pay to a primary care physician will result in an advantage in care.  Hence, paying more will get you faster treatment.

Of course after that process is up and running, there will develop a “expedited – good old boy/girl” network between the  LPNs and PAs in the retail clinics and the LPNs and PAs in the specialists offices to short cut the lines.  This too will further increase the wait times for those who aren’t visiting either the “right” clinic – one with good connections - or a primary care physician.

In this scenario, I can envision pediatricians being a thing of the past.  After all, most children are seen by pediatricians for rather mundane things, many which can, and even currently are, handled by LPNs within the pediatrician’s office.  Many parents will opt for the convenience and cost savings of a retail clinic. 

For many specialists, it is going to be a boom in business.  Pulmonary specialists, urologists, cardiologists, neurologists and EENTs I think will get more business.  For other specialists, it is less of an impact. I don’t know that Oncologists and OBGYNs will get many more patients.  After all, you either have cancer of you don’t – you are pregnant or you are not.  On the other hand I don’t see there being many digital prostrate exams conducted at retail clinics.

And all of these unintended consequences may be exactly (forgive my pun) what the doctor ordered.  It may reduce costs; although I doubt it.  It is bound to cause longer waits for specialists; possible life threatening waits.  The changes will make some portions of health care more profitable, and some significantly less so.

What you can be sure of  is that healthcare as we know it is going to be changing dramatically – and not necessarily for the better.