The New Gatekeepers?


April 10, 2013

Will “the covered” receive care? Our health care coverage certificates may soon look and feel like the American dollar:  a piece of paper backed by nothing. Just like there is no gold backing the U.S. dollar, so there may be no care backing the “coverage guaranteed” certificate you receive under Obamacare’s universal coverage program.

First there are the “narrow networks”? These networks offer fewer choices of medical providers, including primary care doctors, specialty physicians, and hospitals. Narrow networks were instrumental to care-restricting HMOs. This led to a backlash and Congressional consideration of the Patient Protection Act of 1998. Employers nationwide are now buying plans with narrow networks.
Exchanges are expected to have narrow networks, according to Inside Health Insurance Exchanges (HEX). But experts quoted by HEX say backlash won’t happen this time, because individuals will make their own choices on the Exchange; they will be more concerned about affordability than choice of providers. (HEX, March 21, 2013). For example, when employees using Aon Hewitt’s private exchange had the option, 42% picked “skinnier” policies.
Let me ask you a few questions:
  1. What if the “narrow-network” options don’t include the physician you need?
  2. What if you need three different doctors and they’re all on different networks?
  3. What if you’re healthy today and don’t care, but three months after you enroll you suddenly need a doctor that’s not in your network?
  4. What if narrow networks mean long waits for care?
  5. What if narrow networks mean high costs to see an out-of-network doctor?
  6. What if narrow networks mean the demise of your local hospital?
Many California hospitals will close, according to California Healthline, as “insurers are increasingly…excluding certain hospitals and forming smaller networks of health care providers to help curb rising health care costs….the [LA] Times reports.”
Second, do you want a doctor? The ACA could lead to non-physicians taking the place of physicians. As 27 million uninsured Americans get coverage under the ACA, there is a projected shortage of 45,000 primary-care physicians by 2020. Advanced practice nurses (APN), such as nurse practitioners (NP), and physician assistants (PA) are now seeking independence from physicians. Legislatures in 11 states are considering such legislation.
Nursing groups, “concerned about the 2010 health-care law’s looming impact on the availability of doctors,” are pushing for independence aided by AARP, the National Governors Association, and state officials. Many non-physicians are seeking and getting authority to “order and interpret diagnostic tests, prescribe medications and administer treatments without physician oversight,” as stated in The Washington Post. For example, if enacted, the proposed Minnesota legislation (HF 435/SF511) would allow the practice of an advanced practice nurse to include:
(1) the diagnosis and treatment of health and illness states;
(2) disease management;
(3) prescribing pharmacologic and nonpharmacologic therapies;
(4) ordering, performing, supervising, and interpreting diagnostic studies;
(5) prevention of illness and risk behaviors;
(6) nursing care for individuals, families, and communities;
(7) when necessary, consulting with other health care providers or making
appropriate referrals for patients and families; and
(8) integration of care across the continuum to improve patient outcomes.
A nurse does not a doctor make. As a registered nurse, I know we have great skills, but we are not physicians. Even though a nurse has a master’s degree or higher,  she or he has not gone to medical school for four years or the required internship and residency for another three years.
Will patients will be forced by law, policy, or a “narrow network” to see an APN or PA prior to seeing a physician? These non-physician practitioners may be excellent, but they may not have all the skills necessary for correct diagnosis or treatment. And patients may not want to go through a gatekeeper to see a doctor.
Most Americans are relatively clueless about Obamacare. They may or may not even know about mandate to purchase health insurance. Meanwhile, the structures of health insurance and the practice of medicine are shifting wildly beneath their feet, out of view and out of their control. They may soon learn that coverage is not care.
The time to stop Obamacare is now. Just because it’s a law doesn’t make it unstoppable or inevitable. Stopping the federal command and control structures – Obama’s government Exchanges - is critical.
Protecting your freedom and mine,
Twila Brase, RN, PHN
President and Co-founder