While making the case for his health reform package, President Obama argued that his proposal would make life easier for small-business owners.
Unfortunately, Obamacare threatens to undermine a group of small-business owners that is perhaps more important than any other to his reform effort doctors in private practice.
The number of privately owned medical practices has declined sharply in the past five years. In 2005, at least two-thirds of practices were in private hands. That figure has dropped to less than half today and is expected to sink below 40 percent by next year.
Many doctors, specifically those who have just completed a resident specialty, are now choosing not to enter private practice in the first place. Instead, they’re heading to salaried positions at large hospitals. Last year, 49 percent of first-year specialists chose hospital employment.
Obamacare will only exacerbate these trends. Some of the law’s dictates will make it more expensive to operate small practices even though the rules are supposed to reduce medical costs.
Take the new law’s health IT initiative, which pushes doctors to set up extensive electronic health records in hopes of better coordinating care among providers. More information, the law’s boosters argue, means less waste and lower costs.
But many private practices can’t afford to drop five or six figures on expensive health IT systems that may not even save them money.
Boosters of health IT acknowledge that large organizations are more likely to enjoy its benefits. But shoving patients into ever-larger medical groups may not actually bring down costs.
The reason, as representatives of the American Medical Association recently warned, is that big hospital networks have greater market power. They can use that power to keep prices high, and there’s little that insurers and even less that consumers can do about it.
Paying more for treatment doesn’t necessarily guarantee better access or quality. Without an ownership stake in their practices, salaried doctors have an incentive to work the hours for which they’re paid and no more. Fewer hours for doctors means fewer appointments for patients.
History demonstrates that these incentives matter. In the 1990s, several large hospitals bought up practices and put doctors on flat salaries. As Dr. Bill Jessee, CEO of the Medical Group Management Association, observed, doctors suddenly “weren’t working as hard as they were before their practice was acquired.”
Proponents of Obamacare have conveniently ignored these lessons. President Obama’s top health care aide Nancy-Ann DeParle, for instance, wrote in the August issue of the Journal of Internal Medicine that the new law is “likely to lead to the vertical organization of providers and accelerate physician employment by hospitals.” These organizations are called Accountable Care Organizations, or ACOs.
Such vertical integration may prove costly. Already, hospitals lose money on a substantial chunk of the people they see. In New York, for example, hospitals take a loss on more than 70 percent of patients.
That’s mostly because of the stingy reimbursement rates paid by government health programs like Medicare and Medicaid. In 2008, the average Medicare reimbursement in New York represented a 4.7 percent underpayment. Medicaid’s reimbursements were even worse as little as 64 percent of a hospital’s actual treatment cost. Those with private insurance are forced to pay more for care to make up the difference.
Hospitals’ Medicaid losses are compounded by the fact that the program’s beneficiaries use far more medical services than other patients. On average, the privately insured visit the doctor three and a half times a year. Medicaid patients make an average of seven visits.
Yet Obamacare will add 18 million new individuals to the program’s rolls by the end of the decade and thus stretch our healthcare infrastructure even thinner.
Primary care physicians are already in short supply. The Center for Workforce Studies predicts that by 2020 there will be a shortage of 45,000 family doctors and 46,000 surgeons. Unfortunately, Obamacare provides no funding to significantly increase their numbers.
Emergency rooms will have to pick up the slack. The new law could result in as many as 41 million additional trips to the emergency room each year.
The health reform law was sold as a way to fill in the cracks in America’s fractured healthcare system. Instead, it has only made them wider.