Access to Healthcare May Be Our Most Challenging Problem

By Stephen F. Hightower MD FACP

“Health Care is vital to all of us some of the time, but Public health

is vital to all of us all of the time.” C Everet  Koop

fixingushealthcare.com

Saturday, March 8, 2025

Dear Mr. President, Honorable Members of Congress and Distinguished Staff and Fine Citizens,

Access to good health care is the goal of all our efforts to provide more doctors.  It is not insurance alone that counts, it is Access.  An article recently published by Becker’s Hospital Review noted that the average wait time for a new patient visit was 26 days.  Interestingly, our Congressional members do not experience this challenge as they have their own physician care team that provides flu shots, prescriptions, routine exams and consultations.  Thus, they are receiving expedited care which is completely unavailable to so many Americans.  That is why cuts in spending for “waste” in health care do not really address, the key issues of: wait times; provider shortages; Emergency Room overcrowding; or lack of skilled nursing on rehab beds which bottle neck the system.

Technology alone cannot fix this fundamental need for more physicians/providers. Interestingly an evaluation done in 2024 showed that on average, profitable hospitals operating margin was 4.9%, while about 40% of hospitals lost money. Physicians caring for Medicare patients took a 2.8% cut in pay starting in 2025 which is unlikely to motivate accessing more Medicare patients. Health systems are struggling with layoffs and closures (with even Mass General Brigham having two rounds of layoffs due to a $250 million budget gap over 2 years) resulting in significant issues with access.

Similarly, cuts in services have fallen on Labor and Delivery units. This is significantly relevant given that Medicaid’s role for United States births is approximately 40%.  In 2023 Medicare and Medicaid combined to be 39% of total national health expenditures. This was $1.03 trillion for Medicare and $872 billion for Medicaid.  This identifies a 10-year spending increase of 76% for Medicare and 50% for Medicaid, yet access remains significantly unchanged. 

With the increase in the Medicare population by approximately 10,000 Americans daily for the next several years or longer, we are creating a huge challenge to make Medicare Health Care available due to less profitable physician reimbursement.  It is possible that Medicare advantage programs will be the way for the population to go. But with Medicare only paying 82 cents on the dollar for services spent by the hospitals treating Medicare patients, this remains to be seen.

The Medicare Hospital Insurance Trust fund, which funds Medicare Part A benefits, is projected to be depleted by 2036, or in 11 years. Medicare Advantage, which is now covering 54% of Medicare beneficiaries is being criticized for waste and fraudulently questionable practices, but this does not seem to be getting any political focus, due to the cost of eggs, and gasoline.

The funding, access, demand and supply of healthcare, is a complex process. But the payment system will not be the solution for the core problem of too few health care providers.  Neither fee for service or value based reimbursements will fix that.  However the major adjustment which can change is the $83 billion dollars a year that health systems spend on administrative actions, such as hiring staff to navigate prior authorizations, denials, and insurer demands, all to obtain more income, and provide less care.

Unfortunately, the payers have immensely more power than the providers, and the  negotiating imbalance continues to grow in the favor of the payers.  Medicare Advantage is now more than half of Medicare at 32.8 million people and 54% of beneficiaries.  However, it is under scrutiny over wasteful spending and questionable business practices. Investigators revealed an estimated $7.5 billion in questionable risk-adjustments for 2023,  and Senate findings indicate major insurers prioritized profits over patient care through aggressive prior authorization practices, often denying necessary post-acute care services to seniors thru algorithms used by the insurer, suggesting that the patient was not appropriate for a post-acute care facility and was sent home.

In the New Administration, which is promoting reducing wasteful government spending, the level of scrutiny for Medicare Advantage plans and Payers must be improved.  Even though Mehmet Oz the CMS administrator has previously advocated for Medicare Advantage for all, aggressive evaluation of the Payer- Provider relationships should be monitored and evaluated regularly for inappropriate billing or inappropriate denial of care. 

The concepts of Physician Ownerships of practices, hospitals, and surgery centers face significant oversight. Currently there are 250 physician-owned hospitals that are constrained by federal regulations. However,  forward looking data has  shown that physician owned ambulatory surgical centers may be effective in actually reducing costs.

For independent doctors, choices are typically weighted by rising overhead, administrative burden and reimbursement pressures.   Obtaining an improved, work-life balance, and financial security, often makes hospital employment or private equity-backed groups more attractive.

As health systems resume capital expansion and strategic developments that were delayed by the Covid pandemic, there is a strong return to the most profitable service lines, driven not only by growing patient demand but also by a deliberate strategy to strengthen high-margin specialties that enhance market share and financial stability.  Thus, oncology, cardiology, cardiovascular care, orthopedics and spine, and transplant services are being heavily invested with upgraded facilities to attract patients and referrals.

Coming to our ultimate goals for all of this effort ꟷ to provide care; to provide appropriate access for all who are in need; to provide fair reimbursement to those providing care; to provide just treatment to those receiving care; to provide gratitude and encouragement to those who expend personal effort to maintain their health; and to provide well-deserved personal satisfaction for jobs well done.  

Respectfully submitted,

Stepehen F Hightower MD FACP

Rio Rancho, New Mexico

fixingushealthcare.com

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