The ACP Advocate Blog: "You say you want a revolution, well you know, we’d all like to see the plan"
The thing about myths is that there is some grain of truth in them.
I recently obtained a book from the Medical Group Managers Association (MGMA) with survey results for costs of primary care practices. They broke up each primary care specialty into non-hospital or Integrated Delivery System (IDS) owned (Independent) and hospital or IDS owned groups. The sad part is that there were inadequate numbers of surveys for the independent internal medicine practices to even have the category in the book. They only had 9 surveys completed and 10 were required. Using independent family practice as a surrogate for independent internal medicine, it was easily determined that independent general internists can not generated enough income from Medicare office visits to even cover overhead. Hospital or IDS owned practices using provider based billing were easily able to cover overhead and make a little extra income from Medicare office visits.
As a result of this unfair billing system, about 90% of outpatient general internists are now employed by hospitals or IDS’s. Because good primary care loses revenue for their employer, I have witnessed insane office schedules forced on the internists so they literally do not have the time to practice good primary care.
In an ACO, the incentive is to reduce costs compared to previous years of spending and projected spending. The resultant “savings” is then shared with the ACO. In this scenario, good primary care is then valued and supported.
So according to the Mythbusters…the 2 myths are plausible, it just not known if the government intended it to happen or if they were just didn’t care.
Adding to Jay’s thought I have always considered physicians to have a 30 year working life compared to a 40 year working life for the general public.
Additionally doctors are saddled with a horrendous student debt, a topic in itself. My personal feeling is schools have a desire to capture some of their students above average income long after they have graduated.
Moving forward doctors have to pay for their debt, care for their family, educate their children and provide for their retirement on a shortened work cycle.
We have to change the system.
I don't doubt that there is a trend to larger practices, and that hospital owned practices are becoming more common. I also don't question the ecpnomic struggles of physicians in smaller independent practices. The point of my blog post is that these trends, which were occuring long before Obamacare became law and continue today, are not by government intent or design to eliminate indepenedent practices--that is the myth part--but a consequence of market forces that have been buffeting small practices for a long time. ACOs and PCMHs offer the potential of helping physician owned practices by opening up funding and revenue--care coordination payments, shared savings--in addition to their usual FFS reimburesment. And Medicare's decision to select mostly physician owned practices for the ACO initiative, rather than hospital owned ones, suggests to me that at least some in government are betting that dcotors who own their own groups will do better than hospitals in increasing access and controlling cost.
Thank you Bob, for quoting two organizations that have less than zero combined credibility in the minds of independent physicians - the AMA and CMS.
While I agree that the loss of independent IM practices started before Obamacare, this process will rapidly accelerate after the advent of ACOs. The myth that these organizations selected by CMS are "physician-led" is the biggest one you conveniently hide. You also forget what Dr. Emmanuel himself admitted in the now infamous article in the Annals a while ago....that disappearance of private practice of medicine was an inevitable outcome of Obamacare.
I meant to say that about 90% of Montana general internists are hospital or IDS employed. 4 years ago it was about 60%. The market forces you commented on are more accutely felt in a rural environment. Intended or not, the average small group or solo practitioners who don't have lucrative ancillary services like diagnostic imaging can not generate enough income from Medicare office visits to cover practice expenses. So as the percentage of Medicare patients in an internist practice goes up, practice viability goes down. At some point the physician faces the options of leaving practice, becoming a hospitalist, or joining a hospital group.
You are correct that this is not due to the Affordable Care Act. This pernicious problem has been present for years. Because of provider based billing, hospitals (which already consume the lion's share of health care dollars)are given even more money from Medicare A if they employ physicians. Also hospital employed physicians tend to have their labs, referrals, and diagnostic imaging stay with in the hospital system, capturing that revenue also.
This link is part of a series on the situation in Pittsburgh, one that I find happening in my community and seen in other parts of the country as a business model and eliminating competition takes precedent to medical care.