The US healthcare system is facing multiple challenges, one of which is the declining patient experience, particularly in the areas of cost of care and payment processes. In the status quo, many patients feel they lack information about the billing process and are anxious about whether their insurance will be able to cover their medical needs. While patients are one of the most obviously disadvantaged parties in the health system, physicians and other medical professionals are also experiencing significant pressures, which, in turn, further contribute to a worse patient experience.
According to Dr. Oday Alsheikh, ophthalmologist, Medical Director of TLC San Antonio, and advocate for healthcare economics reform, the worsening pay and insurance reimbursements for physicians are driving a shortage of medical care. Patients are unable to promptly get the care they need, with wait times to see private practice specialists taking weeks and even months, as physicians allocate fewer slots for them.
Dr Oday Alsheikh
“The reduction in care is due to having less incentives to continue working in private practice,” Dr. Alsheikh says. “Because reimbursements from Medicaid, Medicare, and private insurance are going down, doctors are either retiring or shutting down their clinics, creating a reduction in accessibility. The lack of transparency in the healthcare system creates a lot of frustration for patients. And, not only do we have a lack of access to care, we also have a lack of access to drugs that are already approved and deemed safe.”
This reduction in accessibility affects patients across all four age groups. For pediatrics (21 years old and below), Dr. Alsheikh says that this is the age group with the highest proportion of patients on Medicaid as dependents, and pediatricians may limit access due to low reimbursement and increasing clinic expenses. Due to fewer available slots, more patients will be forced to visit the emergency room when in need of medical attention.
Most young adults in their 20s and 30s are generally healthy and often forgo health insurance if they believe their incomes are too low to afford it. The exception is in females of childbearing age. In rural areas, there is a lack of access to OB-GYNs as hospitals, clinics, and other health organizations are pulling out due to a high percentage of patients on Medicaid. Dr. Alsheikh says that this demographic is well-protected if they work for employers with good health coverage. However, many companies are choosing high-deductible plans that pass more of the cost to their employees. As the first $3,000 to $5,000 are out of pocket, care is becoming more inaccessible. While generally healthier, young adults are feeling a significant burden from inflationary pressures, such as the growing cost of housing, childcare cost inflation, and mounting healthcare deductibles.
Middle-aged adults in their 40s and 50s face changing health concerns, with most dealing with emerging chronic conditions, such as diabetes, hypertension, and cardiovascular disease, which require constant medication to control. Despite being at their peak earning potential, this age group faces the most financial stressors. Oftentimes, middle-aged adults aren’t just supporting their own health, they’re also supporting the health of two other generations – their children and their elderly parents. Additionally, there are some health conditions, such as rheumatoid arthritis, lupus, and multiple sclerosis, that are very expensive conditions to have at this age.
Finally, seniors on Medicare (age 65+) face the depletion of their retirement funds and the prospect of outliving their resources. Because Medicare covers only 80% of the cost of hospital and doctor visits, most seniors require a supplemental plan to cover part or all of the 20%, or they can choose an Advantage plan, which is managed by private insurers.
Additionally, most Americans on Medicare are expected to live well into their 70s and even their 80s. At this late stage in their lives, supplemental and advantage plans become unaffordable. Eventually, some patients end up on Medicaid, with total reimbursement of Medicare and Medicaid being approximately 84% of Medicare contracted rates, which means Medicaid is paying 4% of the allowed amount. The typical margin of a well-run healthcare provider/organization is about 10-15%, which means that for every Medicaid/Medicare patient, the institution is experiencing a 1-6% loss per patient. This causes access to care to drop significantly, despite worsening health conditions. Additionally, Dr. Alsheikh says that dementia home care is not covered by Medicare, which may require younger generations to care for their parents with dementia, which costs thousands of dollars per month. In some cases, they may have to quit their jobs to provide care for their parents.
“Medicare and Medicaid payments for nursing home care are quite low, which is unfortunate because patients require significant care due to their frail health while labor costs of care staff continue to increase,” Dr. Alsheikh says. “This results in care that is generally substandard, with high liability for the nursing home providers, which are under significant financial distress and have among the highest rates of bankruptcy. It’s entirely possible that access to nursing home centers that care for Medicare/Medicaid patients will become highly limited in the next five years.”
With these numerous problems besetting the US healthcare system, Dr. Alsheikh says that it becomes even more evident that the system is not able to fulfill the needs of patients and physicians alike. A fervent believer in healthcare system reform, he is engaging with various sectors to raise awareness about the problems and work together to create cross-sectoral solutions. He intends to release comprehensive research about the state of healthcare economics in the US, as well as lead initiatives that help increase accessibility through technology and other efficiency-improving methods, leading to better patient welfare – which should be the ultimate goal of every physician.
