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The Doctor Won't See You Now; he's clocked out
Topic Started: Mar 15 2013, 08:45 PM (516 Views)
Banandangees
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ObamaCare is pushing physicians into becoming hospital employees, the results aren't encouraging.

(More and more physicians are employed by hospitals. My family physician, a three physician office, is a hospital owned practice. This is a growing trend in our area. This article "suggest" the reasons why.)
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Big government likes big providers. That's why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain.

Why? Because when doctors practice in small offices, it is hard for Washington to regulate what they do. There are too many of them, and the government is too remote. It is far easier for federal agencies to regulate physicians if they work for big hospitals. So ObamaCare shifts money to favor the delivery of outpatient care through hospital-owned networks.

The irony is that in the name of lowering costs, ObamaCare will almost certainly make the practice of medicine more expensive. It turns out that when doctors become salaried hospital employees, their overall productivity falls.

ObamaCare's main vehicle for ending the autonomous, private delivery of medicine is the hospital-owned "accountable care organization." The idea is to turn doctors into hospital employees and pay them flat rates that uncouple their income from how much care they deliver. (Ending the fee-for-service payment model is supposed to eliminate doctors' financial incentives to perform extraneous procedures.) The Obama administration also imposes new costs on physicians who remain independent—for example, mandating that all medical offices install expensive information-technology systems.

The result? It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that sharply accelerated around the time that ObamaCare was enacted. The biggest shifts are in specialties such as cardiology and oncology

Estimates by hospitals that acquire medical practices and institutions that track these trends such as the Medical Group Management Association show that physician productivity falls under these arrangements, sometimes by more than 25% (more on this below). The lost productivity isn't just a measure of the fewer back surgeries or cardiac catheterizations performed once physicians are no longer paid per procedure, as ObamaCare envisions. Rather, the lost productivity is a consequence of the more fragmented, less accountable care that results from these schemes.

Once they work for hospitals, physicians change their behavior in two principal ways. Often they see fewer patients and perform fewer timely procedures. Continuity of care also declines, since a physician's responsibilities end when his shift is over. This means reduced incentives for doctors to cover weekend calls, see patients in the ER, squeeze in an office visit, or take phone calls rather than turfing them to nurses. It also means physicians no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.

Most hospitals exacerbate these strains by measuring the productivity of the physician practices they purchase in "Relative Value Units." This is a formula that Medicare already uses to set doctor-payment rates. RVUs are supposed to measure how much time and physical effort a doctor requires to perform different clinical endeavors.

Medicare assigns each clinical procedure a different RVU and then multiplies this figure by a fixed amount of money to arrive at how much it will pay a doctor for a given task. A routine office visit has an RVU of about 1.68, while removing earwax has one of 1.26. Setting a finger fracture rates a 3.48.

This system misses all of the intangible factors that help gauge the quality and efficiency of the care being delivered. It focuses physicians on the wrong goals for promoting health, such as how well they code charts to capture higher-value "units."

Hospitals are beholden to the RVU system only because that is how they get paid by the government. Data from the Medical Group Management Association shows that physician productivity in these employed relationships, measured simply by RVUs, declines up to 25% compared with independent practices. The Advisory Board ABCO -0.79%Company, a health-care consulting firm, estimates that when hospitals last went on a physician-acquisition binge in the late 1990s, productivity fell by as much as 35%. Those arrangements mostly failed, and the hospitals divested the stakes they had in individual doctor practices. The physicians went back to practicing out of their own offices.

All of this reduced productivity translates into the loss of what should be a critical factor in the effort to offer more health care while containing costs. Yet hospitals aren't buying doctors' practices because they want to reform the delivery of medical care. They are making these purchases to gain local market share and develop monopolies. They are also exploiting an arbitrage opportunity presented by Medicare's billing schemes, which pay more for many services when they are delivered at a hospital instead of an outpatient doctor's office.

This billing structure exists because hospitals are politically favored in Washington. Their mostly unionized workforces give them political power, as does their status as big employers in congressional districts.

ObamaCare pushes this folly largely based on a naive assumption that models that worked well in one community can be made to work everywhere. President Obama has touted "staff models" like the Geisinger Health System in Pennsylvania and the Mayo Clinic in Minnesota that employ doctors and then succeed in reducing costs by closely managing what they do. When integrated delivery networks succeed, they are rarely led by a hospital. ObamaCare seeks to replicate these institutions nationwide, even though their successes had more to do with local traditions and superior management. That's hard to engineer through legislation.


"DRGs" (Designated/Diagnosed Related Groups), a diagnosis related system, has been the emphasis from the government regulated system for a number of years. It proved to be a confusing, time intensive and a not uncostly system. Now it will be a "RVUs emphasized system," with emphasis on limits of physician productivity. Problem with health care since the government has been involved in its regulation is that these regulations are so often designed by non-medical people..people who don't have the first clue about the practice of medicine. Health care changes again, like we've not seen it before... it definitely will be an adjustment ... more so for some than for others, I suspect. IMO
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Mountainrivers
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" In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain."

I like that idea. It would save enormous amounts of money in eliminating the duplicative costs of renting office space, paying for utilities, fewer clerical personnel, insurance premiums for the doctors and a central place for all our health care needs. What's not to like?
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Banandangees
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The hospital owned practice that I go to hasn't seemed to have eliminated much of any of the things you listed. They have as many ancillary personnel, actually more equipment (hospital owned which is also hospital duplicated) than if they were private practitioners, same billing computers as before. Now what I see in our area, is the competing hospitals are, as rapidly as possible, leasing office space, opening geographically located community hospital based offices at a rate designed to favor their hospital's community exposure over that of their competitor. That's a cost that wasn't there before. It's a race between competing hospitals. A local Osteopathic Hospital a few years back attained approval for a new Osteopathic Medical School (LECOM) with one main goal of producing physician for the "mother hospital's" community, hospital owned out patient offices.


But you have put your emphasis solely on cost containment. When you see your surgeon for your prostate problem, are you hoping for his emphasis to be on cost containment or to have more incentive for quality patient care?
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Mountainrivers
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Banandangees
Mar 15 2013, 09:09 PM
The hospital owned practice that I go to hasn't seemed to have eliminated much of any of the things you listed. They have as many ancillary personnel, actually more equipment (hospital owned which is also hospital duplicated) than if they were private practitioners, same billing computers as before. Now what I see in our area, is the competing hospitals are, as rapidly as possible, leasing office space, opening geographically located community hospital based offices at a rate designed to favor their hospital's community exposure over that of their competitor. That's a cost that wasn't there before. It's a race between competing hospitals. A local Osteopathic Hospital a few years back attained approval for a new Osteopathic Medical School (LECOM) with one main goal of producing physician for the "mother hospital's" community, hospital owned out patient offices.


But you have put your emphasis solely on cost containment. When you see your surgeon for your prostate problem, are you hoping for his emphasis to be on cost containment or to have more incentive for quality patient care?
I'm hoping that he will do both.
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Mountainrivers
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Mountainrivers
Mar 15 2013, 09:19 PM
Banandangees
Mar 15 2013, 09:09 PM
The hospital owned practice that I go to hasn't seemed to have eliminated much of any of the things you listed. They have as many ancillary personnel, actually more equipment (hospital owned which is also hospital duplicated) than if they were private practitioners, same billing computers as before. Now what I see in our area, is the competing hospitals are, as rapidly as possible, leasing office space, opening geographically located community hospital based offices at a rate designed to favor their hospital's community exposure over that of their competitor. That's a cost that wasn't there before. It's a race between competing hospitals. A local Osteopathic Hospital a few years back attained approval for a new Osteopathic Medical School (LECOM) with one main goal of producing physician for the "mother hospital's" community, hospital owned out patient offices.


But you have put your emphasis solely on cost containment. When you see your surgeon for your prostate problem, are you hoping for his emphasis to be on cost containment or to have more incentive for quality patient care?
I'm hoping that he will do both.
"The hospital owned practice that I go to hasn't seemed to have eliminated much of any of the things you listed. "

Is that just a personal observation or do you have data that shows that to be true?
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Banandangees
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You "hope" that he will do both. :smile: I'm, sure he will.

Well, I'm sure in this short period of time of ObamaCare existence, that your surgeon hasn't lost any of his incentive for quality care. But, time has a way of wearing on attitudes when much of the professionalism and freedom of practice as worn on.

But yes, that is a personal observation. I know of no studies that have been made in this short period of hospital expanded practices. I'm sure they will come in time. I've worked in healthcare in Erie and Allegheny counties for a long, long time and am probably much more familiar with hospital and medical practice and of physicians than one who has not. I'll leave it at that.
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Mountainrivers
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Banandangees
Mar 15 2013, 09:37 PM
You "hope" that he will do both. :smile: I'm, sure he will.

Well, I'm sure in this short period of time of ObamaCare existence, that your surgeon hasn't lost any of his incentive for quality care. But, time has a way of wearing on attitudes when much of the professionalism and freedom of practice as worn on.

But yes, that is a personal observation. I know of no studies that have been made in this short period of hospital expanded practices. I'm sure they will come in time. I've worked in healthcare in Erie and Allegheny counties for a long, long time and am probably much more familiar with hospital and medical practice and of physicians than one who has not. I'll leave it at that.
You asked me what I was hoping for. I told you. If I discovered that the only thing my doctor was interested in was his financial gain, I would look for another doctor. I don't feel my current doctors have that goal. They have accepted Medicare and my supplemental policy to cover their fees. If they weren't making enough money via those plans, I'm sure they would refuse to treat me. I don't claim to be knowledgeable about hospitals or medical practice in general, but if I'm to accept your claims, I would need some data to support them.
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jackd
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Quote:
 
ObamaCare is pushing physicians into becoming hospital employees

Bull.
This trend has been observed almost everywhere in the northern hemisphere since the mid 1990,.
This is all happening with or without the Obaba reform passing.
American medicine has historically been largely a small business operation where most doctors cared for patients in small, privately owned clinics (in rooms a adjoining their homes or even their basement.) That,s really not the trend for what has become a very high tech field of work
* Young doctors are coming out of medical school in the U.S. with a staggering debt burden (average of $600,000 (after subsidies). It is very difficult for any of them to think they can invest (borrow more) in a private business.
* Young doctors now love to be surrounded with high tech equipment, fully functionning labs, competent nursing, experienced collegue. None of which is available in a backyard operation.
*Young doctors have studied medecine, not business management. They walk away from all tasks not related to medecine (hiring, firing, sending bills, collecting bad debts, office maintenance,...
* There is a saving of close 50% on malpratice insurance costs for doctors in hospitals (better back-up if something happens.)
* Bigger health care organizations can provide better, more coordinated care, which is a + for the patient.
* Younger doctors all want more free time, a better family life... a trend observed in most workers. That is more easily achieved when being a salaried employee.
At the end of the day, more salaried doctors, will mean better care for patients.
patients benefit from higher quality and better coordinated care, as doctors from various fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital.
* Private doctor business are much more likely to be the cause of ''unfortunate slip-ups'' that cost over 100,000 lives every year.
Dr Marcus Welby has closed his shop for good
Edited by jackd, Mar 16 2013, 01:49 AM.
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Pat
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I lost track of my cardiologist last fall and finally located him last week. I have an appointment to see him and I'll ask him about his new job. Yes new, because he went from one Dr. owned medical company to another bigger doctor owned medical company. The owner has four clinics in the region. And a main cardiology center. Business must be good because my Dr. jumped from one to another. If you want to know where the bottom feeders hang out their shingle, just find out where the low income and welfare clients end up. And then avoid them. The better facilities have the best Drs. and specialists and top notch facilities. that's my experience anyway.
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Mountainrivers
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Pat
Mar 15 2013, 10:00 PM
I lost track of my cardiologist last fall and finally located him last week. I have an appointment to see him and I'll ask him about his new job. Yes new, because he went from one Dr. owned medical company to another bigger doctor owned medical company. The owner has four clinics in the region. And a main cardiology center. Business must be good because my Dr. jumped from one to another. If you want to know where the bottom feeders hang out their shingle, just find out where the low income and welfare clients end up. And then avoid them. The better facilities have the best Drs. and specialists and top notch facilities. that's my experience anyway.
The "bottom-feeders" as you call them are, imo, better people overall, since they apparently eschew the money in favor of treating people who couldn't get care from your high-fallutin group.
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