Stanley Feld M.D.,FACP,MACE
Republicans are trying to figure out what to change in Obamacare to make it work. I believe Republicans should change all the perverse biases built into Obamacare. The result would be a small but important dent in Repairing the Healthcare System.
It is best to start all over again with a bill that puts consumers in charge of their healthcare dollars. Consumers must be responsible and own their healthcare decisions and healthcare dollars. Consumers must drive the healthcare system in order to have reduced costs, increased efficiency of care and competition among stakeholders.
Obamacare is a political strategy by progressives to get more power. It is not about improving delivery of healthcare.
“It is about "redistribution of wealth"… or, by its more common name, "SOCIALISM.”
Republicans do not understand this. They don’t have the courage to call out President Obama or the Democrats.
Democrats cannot or do not want to understand the power of market based consumer driven healthcare because their ideology of central government control of healthcare does not allow it.
Consumers, taxpayer and voters must drive the change to a better, more cost efficient and less dysfunctional healthcare system.
Obamacare’s basic theme is built on hospital ownership of physicians’ practices. If hospitals or hospital systems own all the physicians’ practices in a community, the government has to only negotiate prices with the hospital system. The central government can then control a community and decide on access to care and the rationing of care of the community’s citizens.
The hospital receives a bundled reimbursement for a disease encounter. The hospital divides the reimbursement between the doctor and the hospital.
Once physicians are in the employ of hospitals, the government and hospital systems think that the non-compete clause will hold up in court and physicians will be afraid to leave the hospital systems.
Hospitals think they can lower the salary of physicians during negotiations for renewal of physician employment contracts since physicians will be afraid to leave the hospitals’ employ.
I’ll bet if a group of physicians decided to leave at the same time, the hospitals would be in the trap hospitals set to apply to physicians. Physicians should wake up. Some physicians have.
These are some of the perverse biases Obamacare has created against physician practices and patients.
The biases created against groups of private practitioners and to the advantage of hospital systems costs government and healthcare insurers more than it would if there was a level playing field for practicing physicians. It would create market place competition. Consumers and taxpayers absorb these government overpayments.
A common belief is that the payment system must be changed from a fee for service system to a bundled payment system.
HMOs failed in the 1980’s and early 1990’s because of the pressure of patient and physician dissatisfaction with the quality of care that was provided with a bundled payment system.
Accountable Care Organizations (ACOs) run by hospital systems are the organizations that will take risk and accept a bundled fee. It is similar to the HMO’s that failed previously.
ACOs will fail because it is difficult to predict medical risk. The increases in premiums are the result of the insurance industry’s miscalculation of risk.
Physicians are not willing to take on the risk of patients’ compliance and adherence. Physicians are not mechanics that put a new part in patients and then patients are fixed.
The popular notion is payment reform requires coordinated delivery of medical care in an Accountable Care Organization in which a single institution owns the physicians.
Everyone knows the physicians are at risk. Much of that risk depends on the patients’ responsibility to understand their illness and their behavior toward caring for that illness.
Obamacare is biased against less centralized engagements where independent doctors enter into contractual relationships with their patients. The government has imposed less reimbursement and more paperwork for these independent practices to discourage them from remaining in private practice.
Private practitioners cannot afford to participate in reformed payment plans. Private physicians need complex IT infrastructure in order to comply with the rules and regulations needed to participate in the complex payment reform structure that shifts risk to physicians.
“It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.”
The problem is hospital systems cannot control physician’s medical judgments. Medical judgments are complex and cannot be boiled down to cookbook decision solutions.
Obamacare also provides favorable anti-kickback provisions to hospital systems only when hospital and physicians qualify as Accountable Care Organization. ACO qualification is dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.
In the end physicians shouldn’t care to be in an ACO because their freedom to practice medicine according to their medical judgment could be impaired.
However, many physicians still feel compelled to join hospital systems so they are not left out of the “new age.”
Those physicians who do not participate are joining the surge of interest in the fast growing concierge medicine phenomenon. Consumers want someone to relate to them and not to be a commodity in a failing healthcare system.
I know of only one group of physicians in a small city in Texas who have supposedly taken control of the hospital and enjoy government provided benefits for developing an ACO.
The hospital is dependent on the organized physician group rather than the hospital taking over the physician’s group and dictating how these physicians should practice medicine.
In order for real reform to occur Congress must level the playing field between hospitals and independent private practice physicians. Only then will there be a competitive system where both hospitals and physicians will compete for patient pools.
Congress has to put consumers in the drivers seat, not hospital systems.
The government could set up a new class of “independent risk managers” to help groups and individual physicians analyze and manage risk.
Managing risk depends on patients assuming responsibility in the participation in managing their diseases.
Hospital systems do not evaluate risk very well. Neither does the healthcare insurance industry or the government.
Government should be the facilitator of improving care, not the manager of the healthcare system.
“Obamacare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.”
Another simple solution to increasing costs would be to provide physician owned private groups and individual physicians with the same reimbursement provided to hospitals and hospital owned physicians.
“ 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.”
This is true in all coding categories. The difference produces a sizable profit incentive to the hospital at a great cost to government.
Hospital systems are driven to buy physicians’ practices to take advantage of the difference since money-making long inpatients hospital stays are becoming a thing of the past with new advances in medical and surgical care.
The profit margin from owning brick and mortar is shrinking and the profit from owning intellectual property and surgical skills is increasing. Hospitals want to take advantage of this phenomenon.
Why is the Obama administration doing this?
Once the hospital own the physicians in the community the government can then squeeze the reimbursement to the hospital system. Hospital systems will have no option but to accept the reduced reimbursement.
It is called “got you in checkmate.”
It has happened before. This strategy has never worked.
When will the government ever learn?
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone
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