By Paul Goldfinger, MD, Editor @Blogfinger.
About two years ago a large and prestigious cardiology group in Morristown, an independent organization which had been in existence for 50 years, was bought out by Atlantic Health, a mega-medical system akin to Meridian. The doctors in that group, all graduates of the finest training programs in the country, became hospital employees. They did that because they were forced to, not because they wanted to.
A cardiologist in that group told me that the Medicare reimbursements for office procedures and patient visits had been cut significantly and were much lower than the fees for such services provided at the hospital. So, because of the financial stresses, the group had to give up and sell out.
Their practice was destroyed by a roaring ill wind that has been rapidly blowing apart the private practice of medicine throughout the country, and that ill wind was created by the government (Obamacare) through Medicare payment reforms which force doctors out of private practice and favor the growth of corporate healthcare organizations such as Atlantic Health.
At Blogfinger we have been writing about this theme for the last three years: What will happen to the quality of healthcare and, more specifically, the doctor-patient relationship, as a result of the new government-driven system called Obamacare (aka Affordable Care Act–ACA ?) For awhile there were no answers, but now the truth is forcing itself out into the open. Instead of what they say, we are beginning to see what they do.
A decline in quality is already happening, and many of you have experienced either the loss of your regular doctor due to insurance limitations, or the reduced availability of care, or worrisome changes in how care is delivered. Some doctors have left or are planning to leave the profession.
In the Wall Street Journal on Dec. 7, an op-ed article by Scott Gottlieb, MD, an expert on health policy, appeared called “Obamacare’s Threat to Private Practice” *
A survey of 20,000 physicians found that only 35% were in independent practices compared to 62% in 2008. This shows how quickly the private practice of medicine is being dismantled.
Dr. Gottlieb says, “Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.”
He also says that Congress should remove the pervasive “biases in ObamaCare” that favor hospital ownership of medical practices.
Perhaps you are thinking, “Well, so what if doctors make less money and lose control of their practices?” There are a number of responses, but I would say that most doctors are, by nature, devoted to providing quality care and placing the welfare of their patients above all concerns. When they become employees, they lose much of the control over quality and they are disconnected from the feelings of responsibility that doctors in private practice typically have towards their patients. Most doctors would agree that medicine run by bottom-line oriented hospital corporations will result in reduced quality.
Wait and see what is coming in the future unless this trend is reversed.
Nov. 10, 2016 note: The situation has worsened since this piece was written in 2014. Medicare, which has been influenced heavily by Obamacare, is now in serious financial trouble, and ACA premiums are due to rise sharply.
The comments section from 2014 is quite good and can be added to now; especially in view of the sudden U turn about to happen in Washington. —-PG
Satisfied:
This is from the CNN Political Ticker (March, 2014):
“Obamacare remains unpopular: Just about every national poll indicates that more Americans disapprove of the law than support the measure. According to the most recent survey, conducted just over a week ago by CBS News, 53% of Americans gave the law a thumbs down, compared to 41% saying they approve of the Affordable Care Act.
“Other polls conducted earlier this month had similar results. By a 53% to 43% margin, voters in a George Washington University/Battleground survey oppose the law. By a 46% to 38% margin, Americans questioned in a Kaiser Family Foundation poll said they had an unfavorable view of Obamacare. Fifty-three percent of adults nationwide surveyed in a Pew Research Center poll said they disapproved of the law, with 41% saying they supported it.
“And according to a CNN/ORC International survey, 57% of adults nationwide oppose the measure, compared to 39% supporting it.
“This lack of support for the law is nothing new. While the numbers have rebounded a bit since last fall’s disastrous roll out of healthcare.gov, overall the measure has been unpopular with many Americans dating back to the first debates over the legislation in 2009.”
On Nov. 17, 2014, Gallup said: “WASHINGTON, D.C. — As the Affordable Care Act’s second open enrollment period begins, 37% of Americans say they approve of the law, one percentage point below the previous low in January. Fifty-six percent disapprove, the high in disapproval by one point.”
Maybe I’m alone here, but a majority of Americans wanted the ACA. They voted for the Congressional members who supported it. They twice elected the President who signed it into law. While the law has some warts, this is what America wants and needs. The people have spoken.
As a healthcare worker, I believe that individuals need healthcare. What I don’t believe is that Obamacare is the answer. Like it or not, the “rich” will always have access to healthcare as will the poor. It’s the working poor and the middle class who are all too often left out in the cold, and Obamacare has exacerbated this problem.
The American Society of Actuaries estimates a 32 percent increase in the cost of covering people in the individual market as a result of ObamaCare. A report by the House Energy and Commerce Committee reveals “consumers purchasing health insurance on the individual market may face premium increases of nearly 100 percent on average, with potential highs eclipsing 400 percent.” The same report shows “small businesses can expect average premium increases in the small group market of up to 50 percent, with potential highs over 100 percent.”
The Wall Street Journal reported, “Several restaurants, hotels and retailers have started or are preparing to limit schedules of hourly workers to below 30 hours a week…. CKE Restaurants Inc., parent of the Carl’s Jr. and Hardee’s burger chains, began two months ago to hire part-time workers to replace full-time employees who left….”
Approximately nine-in-ten seniors with retiree benefits will lose their retiree prescription drug coverage through their employer under the Democrats’ health care law.
Estimates from CBO and the Joint Committee on Taxation (JCT) confirm that the Democrats’ health law is a one trillion dollar tax hike on families and employers. The law contains 21 tax hikes, and more than half of those fall on the backs of Americans earning less than $200,000 per year for singles and $250,000 per year for married couples – a clear violation of the President’s pledge to avoid tax hikes on low- and middle-income taxpayers.
According to the Obama Administration’s own estimates, Obamacare will require American job creators, families, and health care providers to spend over 190 million hours per year on compliance.
This is just the tip of the iceberg. I am already seeing the impact of this legislation on the front lines, and it is just getting started.
In response to some thoughts expressed above by some commenters:
I think that many — I believe a majority — of Americans — believe the health care system was working fine before all the changes in the last few years. My concern is that when the Government decides that the majority must suffer to benefit the minority, things are getting out of wack. The healthcare system that we knew and loved 5 years ago will be gone in another 5 years.
While I recognize that there are those who want the US to turn into France or the Netherlands, I am not one of them. I do not think healthcare should be held hostage to a social justice agenda.
The US is getting to the point of becoming a socialist country. We subsidize the lifestyles of about 1/3 of all people in the US through health care subsidies, housing subsidies, food subsidies, cell phone subsidies, income subsidies, etc., etc., Where does it end? And why am I paying to subsidize some many people?
Joe: I find your comment to be interesting, especially where you see EMS workers actually providing followup patient care. There is no doubt that all those millions of newly covered patients will have to be seen somewhere, but it won’t be in the offices of those blue-chip “best” docs that everyone would like to see, because choice will be taken from most, and choice was one of those wonderful features of our “old” system. For my medical group, we did not provide HMO care for our families and employees because all of us wanted to retain choice.
I think that clinics will have to be set up. When I was a resident physician in a big city private hospital, all of us and all of the attending physicians would work in clinics to provide free care to the poor. Now, those “poor” will receive Medicaid, which was always crappy and probably will continue to be so. I’m afraid that those millions will be disappointed, as you pointed out.
Yes physician extenders including “nurse doctors” will be providing front line care—hopefully under the supervision of actual doctors, but that may not be in the cards.
As for those “best doctors,” that term acknowledges the fact that there is a spectrum of quality (related to training, experience, intelligence, commitment, compassion, etc.) and why should such a doctor who became “best” after years of hard work accept an employee job in some clinic run by hospital bureaucrats? He/she will seek out prestigious, well paid jobs at places where most patients, unlike today, will have no chance of accessing. A superior doctor will expect and deserve more than $40.00 for an office visit. Best lawyers get $500 per hour or more. Why should anyone think that a doctor should not get paid according to his worth? The new system is turning great doctors into broken cynics, but many of them will find a way to practice privately outside of the one-size-fits-all Obamacare.
I have always felt that this law will drive a wedge in society. Yes, those 20-30% will receive a basic level of care that OGJamie alludes to through clinics and the ED (emergency department) wards.
But those that can afford it, those that have excellent insurance coupled with cash will be able to access the highest, best levels of care through private practices and referrals.
A significant portion of society will see an elimination of the doctor-patient relationship outside of the brief ED or clinic visits, especially with the rise in physician extenders (for example physician assistants.) Those that can afford it will retain it, but those really high quality specialists will be only available to a small segment of society….
If anything, as the ED becomes the most frequent method for accessing health services, and EMS becomes the method for people to physically just get to the ED, these agencies will look for ways to alleviate non-emergent transports and we may see a rise in the EMS-patient relationship through follow-up and house calls.
“They believe that America must reallocate money and effort to bring the bottom 20-30% of citizens up to a basic quality of healthcare and that no one should enjoy a higher quality of care simply because they are affluent.”
So, enjoying proper healthcare is on the level of being able to buy a luxury car or something similar simply because one owns/earns more? I think in a nation as great as we think we are, all people should deserve equal quality healthcare, regardless of income. This isn’t luxury goods we’re talking about, we’re talking about basic level services that a country like ours should provide to all citizens, not just those privileged enough to afford it or have a nice job.
Think about your comment. You are directing it at up to 20-30% (not sure where that figure comes from) of your fellow citizens. Think about how many kids are included in those numbers. Think about how many of your neighbors or family or friends may now – or in the future…it can happen to all of us – may be included in those numbers.
There were times in the ’80’s and ’90’s when hospitals tried to buy physician practices—usually those of primary care doctors in border turf areas. The goal was to have the docs refer their patients to the owner hospitals. But that didn’t work out for the hospitals, and the practice stopped. But it has now come back with a vengeance with the help of government regulations that effectively provide subsidies to the large mega-hospitals.
Unless those regulations change, the private practice of medicine will become obsolete, except perhaps for boutique practices for people who can afford them.
Once the next generation of doctors emerge on the scene, private practice will seem like a historic footnote.Those new doctors will accept their fate as employees and they will have no idea of what the “doctor-patient relationship” was about.
How will all this effect patient care? We will have single payer, guideline-driven healthcare, and it will be the norm. The lowest common denominator will be promoted as excellence.
–Paul
The ACA was specifically designed to erode/eliminate the employer based healthcare system and to force independent practice physicians into joining corporate-run health systems. It is also a system designed to redistribute wealth. Physicians, as employees, will have to follow practice protocols dictated by their corporate owners — or they are fired. Corporate owners are not concerned with maximizing health outcomes or quality of care for individual patients. They want the cheapest care for a population of patients that meets a basic quality standard.
If you read Democratic health policy experts writings, they are quite explicit in their desire to achieve these goals. They believe that America must reallocate money and effort to bring the bottom 20-30% of citizens up to a basic quality of healthcare and that no one should enjoy a higher quality of care simply because they are affluent. This is pure Marxist thinking, but its the ideology driving the ACA. They also want a dynamic that will ultimately lead to a single payer system controlled by the federal government.
I saw today that 58% of Americans are opposed to the ACA. That’s a clear majority — so let’s hope the new Congress will take this issue on next year.
Before some of you ACA supporters have a fit, I would like to say that this opinion piece is focused only on the physician/quality topic. Please read the Gottlieb article before condemning it.
It doesn’t mean that there are no benefits to be accrued from the new system. One aspect that I would love to see succeed is the idea of universal care, however, that may not happen for a variety of reasons, and, in the end, it remains to be seen how many people will get healthcare who did not have it before. And wasn’t that the main reason for the ACA in the first place?
The data on how many people enrolled in ACA approved plans must be divided into those who had coverage before and those who did not.
Many of the goals of Obamacare are lofty and worth supporting, such as elimination of fraud and abuse, but we haven’t heard much about that, and in general, I support free market solutions to problems such as that, with government/Congress supplying a framework to enable reforms to occur without actually running the system itself. Physicians need to be in charge.