Remember your personal physician? He or she may not be yours much longer. And even if they are still your doctor, the odds are they are not really working for you. Soon, most doctors will have abandoned their private practices and become employees of hospitals, multihospital affiliations, or the Government. Only 35% of doctors currently describe themselves as independent, compared with 62% in 2008. This trend will undoubtedly continue; a doctor graduating from medical school today has little or no chance of starting their own solo practice. How did this happen, and why does it threaten patients?
The main culprits are the Government, insurance companies, and large hospital systems. As a result of the Obamacare payment provisions, the Government essentially encourages hospitals to “own” doctors. With inscrutable logic, the Government pays more for the exact same medical procedure or doctor’s visit if it is done in a hospital clinic rather than in an independent doctor’s office. This is a strong incentive for hospitals to buy physicians and their practices, thereby controlling payment and referral sources. Doctors may have no alternative but to take salaried hospital positions if their practices disband.
On top of this, Federal rules and regulations regarding electronic records and medical partnerships make it prohibitively expensive for all but the largest physician partnerships to compete. Recently, over a quarter of a million doctors were informed their Medicare and Medicaid payments are being reduced because they have not sufficiently adopted electronic medical records. Small physician practices, which cannot absorb the costs entailed, are hurt the worst - just another nail in their coffin.
The Government’s willing partner in the dismantling of private practice is the insurance industry. Even before the Affordable Care Act, insurance companies advocated “narrow networks” – corporate jargon for deciding which doctors patients could choose – to keep costs low, offer reduced premiums and broaden coverage (without mentioning the prospect of generating higher company profits). Put simply, one way for insurance companies to control premiums is by limiting patients’ choices of doctors. These networks could change every few years and every time they did, some doctors would be unceremoniously shown the door.
None of this bodes well for either American medicine or patients, no matter how the insurance industry and the Federal bureaucracy spin it with business-speak like “consolidated health systems”, “coordinated care delivery”, or “pooled financial risk”. These large consolidated hospital systems eliminate any possible benefit derived from local competition. When Wal-Mart comes into a community and the corner mom-and-pop grocery store closes, locals may be offended but at least everyone generally benefits from greater selection and lower prices. In today’s brave new healthcare world, as corporatization increases there is more depersonalization, less selection and prices do not drop.
But there is a far more ominous implication. The centuries-old bond between patient and physician, described by Hippocrates 2500 years ago, is in jeopardy; the mutual trust relationship is frayed. When physicians become corporate (or Government) employees, their loyalties are divided between their employer and their patient. How does the doctor determine what advice or treatment to give a patient? Is it what is in the patient’s best interests or is it adhering to performance goals and satisfaction surveys increasingly used as rewards or penalties that factor into the doctor’s salary? Fortunately, in most cases, there is no conflict. When there is, most doctors still act in their patients’ best interests. But now there is an ever-present threat the doctor will defer to a “quality improvement initiative” designed by some distant bureaucrat.
This new disconnect between patient and physician is exemplified by the electronic medical record. Despite never being rigorously tested in real-life situations, the computerized record was introduced to medicine two decades ago at a cost of billions of dollars. In 2009, the Government provided billions of dollars more in bonuses if providers implemented the electronic medical record.
The computerized record is admittedly easier to read and transmits information more easily to a distant site than its paper counterpart. But the electronic record has introduced an unseen barrier between patient and physician. Doctors now stare at a computer screen while they talk to patients. Then they spend an inordinate amount of time completing electronic records, time better spent talking to patients. Cut-and-paste and poorly designed templates create bad habits when doctors question and examine patients. And electronic records are hardly secure: millions have been hacked or stolen, the information in millions more is routinely sold to third parties. Hardly a technology to engender trust.
Society has always had a love-hate relationship with doctors. Some physicians are lampooned as imperious jerks and others are accused of doing too many tests and procedures (the President is among the accusers). However valid these charges, one thing has always been true: the one who must look the patient in the eye is the doctor (when they are not staring at an electronic record). With rare exception, even the most arrogant and venal physician has the patient’s best interests at heart. Is the same true of the new businessmen in charge of healthcare? With physicians becoming pawns in a much larger game, who will look out for patients? We may never again be completely sure.
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