By Paul Goldfinger, MD, FACC
Now that the ACA has become a certain reality, the two areas that interest me most should begin to come into focus out of the mist. One has to do with how the quality and availability of healthcare will be affected, while the second is about how the practice of medicine by physicians will change.
The evolution of all this will start out slowly and then become an avalanche over the next five years as new regulations come into play. At this time, there is no way to be certain about much of the details, because the ACA is, in large part, largely a skeletal plan waiting for the blanks to be filled in. There are many complicated aspects to all this, so let’s get specific: What will happen to physicians and the doctor-patient relationship?
It is clear that there will not be enough doctors to meet the needs of all the patients who will have health insurance. Care will be given by teams of providers, supervised by doctors who will delegate tasks to all sorts of physician extenders like nurses, technicians and PA’s. Doctors will no longer have a personal relationship with patients. Care will be largely governed by practice guidelines, and physicians will become cogs in industrial-size health systems. Most doctors will eventually become employees on salary; fee for service reimbursements will disappear as will the private practice of medicine by solo or small group practices.
Here are examples of the unsettling current climate that I have observed recently by talking to three physicians.
Doctor A is a solo internist who has been in practice for about 10 years. He is 42 years old and he is loved by his patients and highly regarded by his colleagues. He has just announced that he will soon close his practice and seek work in some type of large-scale setting like the VA, the military, or within a hospital-run mega-organization. The reason is economic: declining reimbursements and rising costs have caused his “business” to fail.
Doctor B is a 52-year-old cardiologist who is a superb and caring clinician who is consistently mentioned in the “best doctor” rankings. His current practice hours are long and exhausting. He and his colleagues have formed a defensive alliance — a large group practice with other cardiologists — but he cannot keep up with the rising demand for his services accompanied by sharp declines in reimbursements (especially from Medicare) and by rising costs. Recently he stopped taking new patients, and his group had to fire some excellent employees.
Doctor B says that morale is low among his colleagues because they see no way to pedal faster while maintaining quality and income. He tells me that I “got out just in time,” and he is glad to be in the final phase of his practice.
Doctor C is a 3rd year internal medicine resident at a city medical center. He tells me that half of his fellow residents will go on to become specialists. Another quarter are seeking salaried hospital jobs. Those “hospitalists” work 7 days on and 7 days off. The final 25% are seeking jobs in outpatient settings, but almost none of them are planning to open their own practice. He and his fellow residents expect decent pay in exchange for a better life style. Doctor C is satisfied with that conclusion. The new doctors coming out will learn to be comfortable with all the changes that the ACA will bring. They won’t miss a style of medicine that they will never experience.
Most practicing doctors today are feeling discouraged about the prospects for their profession. They see the ACA as destroying a system that could be improved but should not be changed wholesale, as will occur under the ACA. About 55% of physicians said that they would vote for Romney, vs. 36% for Obama.