The Coming DRexit

Brexit was a British version of “I’m mad as hell and I’m not going to take it anymore,” a famous line from the film “Network.” Brits were fed up with intrusive and nonsensical regulations from the European Union, including whether eggs could be sold by the dozen — really important stuff affecting the lives and well-being of our neighbors across the pond.

“Frexit” may be the next iteration, as one of the leading French presidential candidates, Marine Le Pen, promises voters a referendum to leave the E.U. Donald Trump’s election to the presidency is the American version, in which voters chose to leave behind the political and media Establishment and favored a new direction.

Now, in medicine, a similar movement is called “DRexit,” as described by Dr. Niran Al-Agba, a pediatrician in Washington State, who wrote about this in a blog post — and it may be pushing physicians away from stifling bureaucracies of government-run health care. Endless rules, regulations, and mandates are turning physicians from healers into robots and transforming the medical clinic into the post office or the Department of Motor Vehicles.

The practice of medicine for decades has been micromanaged by the government and insurance companies. First were the price controls, dictating what physicians were (and are) paid for their work, regardless of costs. This is not so in law, another service profession. Lawyers charge by the hour and their rates are based on experience, reputation, and the value they provide to their clients. They also charge separately for their expenses. Not so in medicine.

Second was Obamacare, with its insurance networks limiting physician access to patients and interfering with the all-important and often long-standing physician-patient relationship.

Third was MACRA, a bit of congressional legislation from 2015. It was Big Brother on steroids, perched on the shoulders of American physicians. MACRA replaced the Sustainable Growth Rate (SGR) that dictated how much physicians were paid for their services. The SGR tied payment rates to general inflation, ignoring that medical inflation outpaces the consumer price index at typically twice the rate — meaning physician payments were not keeping pace with their costs of doing business.

Congress ditched the SGR to the relief of American physicians, but replaced it with MACRA, full of quality measures and incentive payments based in large part on checking boxes in electronic medical records and other meaningless processes. This program also encourages physicians to do less, and prescribe less expensive medicines and treatments — treating the federal budget rather than their patients.

Upon graduating from medical school, new physicians take the Hippocratic Oath, promising to “first do no harm.” So what happens when government mandates change the promise to “first spend less money”?

At some point, physicians cry uncle and head for the exits — the “DRexit.” Many will opt out of Medicare and Medicaid, the government-run insurance plans covering about a third of the U.S. population and generally the most vulnerable — the elderly and the poor. Commercial insurance companies aren’t much better, as they often piggyback on the federal programs with similar rules and regulations.

As physicians “DRexit,” many will not accept any insurance. They’ll instead require patients to pay cash for their services and then submit their bills to their insurance company, whether Medicare or Anthem.

Related: Patients and Their Doctors Can Talk Again

The chattering classes of the media and the Left fret over Republican plans to repeal and replace Obamacare and who might lose coverage if Medicaid expansion and insurance mandates are curtailed or ended. What is conveniently or intentionally overlooked is the fact that insurance coverage is not the same as health care.

If enough physicians “DRexit” and choose not to accept Medicare, Medicaid, or commercial insurance, all the Medicaid expansion in the world doesn’t mean these patients will have a doctor to see when they are sick. Rather than worrying only about who gains or loses coverage under repeal/replace, policymakers should not forget those who may or may not provide such coverage.

Brian C Joondeph, M.D., MPS, is a Denver-based physician and writer. 

Categories: Uncategorized

2 replies »

  1. I agree Dr. Joondeph and in America there should be a system where doctors are free and not forced to provide their services. Read the book Atlas Shrugged. A book of fiction where the talented of the world walked away because they were being forced to work for others. Currently, there is every incentive to be on a “government insurance” program and so much less incentive to get it through work.

    I like how you included that doctors won’t accept commercial insurance either. I myself just had a situation where I needed a new doctor due to a move. My friend recommended his Primary. When I called to request him as my new doctor the receptionist (was rude, as I feel they mostly are) and literally laughed at me, telling me “he hasn’t accepted new patients in years”. I admit, I don’t understand the provider-side as much as I do the employer/insurance side of things, but this seems wrong.

    I can’t comprehend a business where you don’t want or need new clients and there are no incentives to taking on more patients. It didn’t matter what insurance company I had, I couldn’t pay this great doctor directly to take me on as a client. And in a ‘free market’ system, that seems like a problem.

    I imagine a private system where if you need a knee done, the patient is paid by the insurance company whatever the avg. charge to get a knee done in any particular area. (lets say 20k for fun) Claim is paid, insurance company is done. Then the patient goes around and shops based on quality and price and ends up paying a better doctor 23k.

    They paid the extra 3k because the Doctor was the best at doing that particular procedure. Why can’t we have a system (alongside the current or in addition to) where doctors and hospitals compete on price and quality and paid direct by the patient. And a third system (direct care former VA) that is for the poor.

  2. Agree wholeheartedly. As a front line provider, we are absolutely killed with hyper-regulatory nonsense on a daily basis. There is at least a small amount of chatter about burden and the costs and meaningless data entry activity at this point. But even with this chatter, not a day goes by that some else wants us to “click” a box here or “document” here or data enter here for a new program flailed out by the Joint Commission, ONC, CMS, or whoever wants to pile on the front line MD. Recently I just heard that the Amer College of Radiology wants us, the front line MDs to “preauthorize” any advanced imaging so the RADIOLOGIST can get paid. Right. Make me do extra work so someone else gets paid. Do you think as a Board Certified Orthopaedic Surgeon, that i have some idea what test I need and want? Btw, i do. Funny how the ACR does not want the radiologist to have to do this, but the hardworking front liners to do it for them. Easy, make someone else do it. That is typical of all these programs. Make the doctor do ALL the data entry, hey, its free! Those days are over. They are driving us out practice at a record pace. There are a few fighters left, like Dr. Al-Agba (Mommy Doc), but we are getting wary. The problem is we are losing great clinicians, with vast experience, that have smelled the blood and vomit of real patient care, not some box checker, clicker, screen bureaucrat that “thinks” they know better. All these programs “sound good” but are not tested, studied, shown to be better, and certainly do not take into account burden, cost and outcome improvement. The blowback is coming, the the Drexit already is happening. But when it breaks, we are going to be in big trouble in the US. As after you drive us out, we are not coming back.