Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD

June 10, 2011: Medicine's 'Tipping Point': What's Next?

By Rob Tenery, MD on June 10, 2011

In his book, The Tipping Point, Malcolm Gladwell describes his concept as “the moment of critical mass, the threshold, the boiling point.” (1) Although he cites examples such as the precipitous fall of the crime rate in New York City and skyrocketing sales of Hush Puppy shoes, his premise is that little things can make a big difference. The ‘edge-of-the-cliff’ concept.

It appears that this country’s health care delivery system is rapidly approaching its ‘tipping point.’

There are at least five areas that collectively have taken us to this abyss. They are the rapidly growing patient population, the explosion of medical technology, the growing scarcity of funding resources, the Patient Protection and Affordable Care Act of 2010 (PPACA), and the increasing attrition of physician participation in Medicaid and Medicare.

Taken separately, we can see how each of these factors has played a role. With the medical advances that have increased longevity and decreased infant mortality, the population growth is not unexpected. Add to this the millions of individuals who are in this country illegally and tap into our, already strained system. The entrepreneurial freedoms have given us technological advances that were only dreams a generation ago. Unfortunately, there are not enough funding resources to make all these advances universally available, thus prioritizing and rationing are becoming more common. Adding the anticipated 32 million more covered lives into the federal funding programs under the PPACA will plunder the existing system even more. The final factor is the insidious attrition of physician participation from the Medicaid and Medicare programs due to the eroding reimbursement rates.

Unless some of these issues are addressed, it seems almost inevitable that the system, as we know it, will ‘tip’ as in Gladwell ‘s critical mass hypothesis. But in what direction?

The number of doctors in Texas accepting Medicaid patients fell 25% from 2000 to 2010. The percentage of doctors accepting all Medicare patients dropped from 78% to 66% during that same period. (2,3) Coupling this loss of physician participation with the increasing influx of the baby-boomer generation and new Medicaid lives into these programs serves as a caldron of uncertainty.

With no permanent fix in the Sustainable Growth Rate in the Medicare program and a planned shift of 500 billion dollars out of Medicare funding to pay for the added costs projected with implementation of the PPACA, it is even more likely there will be a continuing drain of physicians who opt out of Medicaid and Medicare. The American Association of Medical Colleges (AAMC) feels the nation could face a shortage of as many as 150,000 doctors in the next 15 years and that 45,000 more primary care physicians will be needed by 2020. “It will take 10 years to even make a dent into the number of doctors that we will need out there,” states Atul Grover of the AAMC.

As long as our elected leadership fails to realize that health care reimbursements must keep pace with the advances in technology and a burgeoning population, there will be no satisfactory resolution. Funding solutions must come from more than just squeezing down on reimbursement rates, increasing efficiencies, eliminating abuses, and shifting monies from one federal program to the other. They must abandon their narrow-minded loyalty of tying funding prerequisites to a percentage of the GDP. Which costs are too much when lives are at stake? There must be limits, but how high do we set the bar?

It seems unlikely the government will sit idly by if large numbers of patients can’t find proper health care services. One option would be to allocate more of the basic screening and minor medical services to non-physician providers. Much like what is happening currently, but in larger numbers, such as with nurse practitioners, midwives, etc. That can only go so far. If conditions deteriorate to a point where ‘public health,’ in a broader sense, is endangered, more dramatic changes would have to be implemented. One only has to look at the state of Massachusetts to see where our system might be headed.

In April 2007, Massachusetts passed legislation requiring its residents to have health insurance. As a result, the uninsured population has reportedly fallen to 5% and added 300,000 covered lives to its roles. Due to low reimbursement for primary care services there is now a shortage of primary care doctors. In response to the longer waiting periods to see primary care doctors, many patients are seeking primary care services from specialists which can be more expensive or showing up at emergency rooms in higher numbers (reportedly a 7% increase since implementation of the legislation in 2007). In response to these increased costs and utilization, in the 2009-2010 Massachusetts’ legislative session Senate Bill 2170 was introduced that stated “Every health care provider licensed in the commonwealth which provides services to a person covered under ‘Affordable Health Plans’ must provide such service to any such person as a condition of their licensure, and must accept payment at the lowest of the statutory reimbursement rate (110% of Medicare or less…).” Although the proposed legislation was reported out of committee favorably, it died as the session expired, without passing either the House or Senate.  The bill has now been re-filed by Representative Michael Costello as House Bill 1470 (HD 1434) for the 2011-2012 legislative session. Similar bills are being filed in the Massachusetts Senate. (4, 5)

Many physicians are already speaking out.  Outside of Medicare and Medicaid, some don’t accept insurance of any kind.  They have given up on the system that appears to be leading them into a role of indentured servitude. What happens when the only choice is more doctors and that solution is years away? Will our elected leaders attempt to emulate Massachusetts? Will whoever is in the White House bypass the legislative process with Executive Orders to enact whatever laws are felt necessary to address these critical deficiencies? Will those who are involved establish a meaningful dialogue with the physician population to look at real solutions? Will physicians tolerate not having meaningful input if they are not at the table?

“The situation in malpractice liability coverage reached crisis levels in 1975 during the post-oil-shock recession. Commercial insurers left large numbers of physicians without coverage. In California, many physicians were facing doubling or even tripling of their premiums within a year’s time. Many practices closed or the inflated prices of the premiums were passed on to the patients. In an act of desperation, physicians organized a work slow-down, only performing emergent care. Governor Jerry Brown almost immediately called the state legislature into emergency session. Out of that legislature came The Medical Compensation and Reform Act of 1975 (MICRA)…

Following the passage of MICRA, malpractice settlements have been 53% less than the national average…while malpractice premiums have increased only 7% annually versus 17.5% per annum nationally…” (6,7)

It seems history has a way of repeating itself.


1. Gladwell M., The Tipping Point, Little Brown, 2000.

2. http://www.texastribune.org/texas-health-resources/health-reform-and-texas/texas-doctors-drop-medicaid-and-medicare-patients/.

3. Consultation with the Texas Medical Association Knowledge Center

4. http:/rangelmd.com/2010/04/Massachusetts-to-force-doctors-to-accept-medicaremedicaid-or-lose-license/

5. Bill Ryder Esq. Government Relations Counsel for the Massachusetts Medical Society.

6. Zuetel KR. The Medical Injury and Compensation Act of 1975; Then and Now. International Journal of Cosmetic Surgery and Aesthetic Dermatology. Volume 5, number 2, 2003: 201-206.

7. Tenery RM. In Search of Medicine’s Moral Compass. To be published.

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