By Dr. Joseph Rosin
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The change is coming much more rapidly than I imagined. Independent physicians are starting to vanish, fast. Economics drives behavior. In the mid 1990’s, doctors merged with hospitals to form networks in response to the HMO plans. The percent of doctors who were independent, private practitioner began to drop. Patients generally disliked the HMO programs and insurance companies went back to a model which allowed more choice. Most of these networks fell apart.
Fast forward to today. In the L.A. Times, there is an article about the movement of doctors to affiliate with hospitals, again. (Link)
This is in direct response to the provision in the new healthcare legislation for Accountable Care Organizations. (Link)
Doctors are as concerned as anyone about making a living. They realize that current government policy does include the independent practitioner. HMO’s were encouraged by government policy which took shape in the 1980’s. (The history of corruption with some of these early plans makes for great reading)*. Today we have the Medicare advantage plans as a result. The insurance companies will not touch them unless they get 15% more from CMS than they pay individual doctors. It is not hard to see that the government favors big organizations as proxies to control doctors and health care.
All Americans should have entrée to medical care as a matter of social benevolence. It makes the world a little kinder and more comfortable for us. It is on par with food and shelter. It has become increasingly expensive to access a doctor, largely due to attempts at government control. The politicians’ will is to be in charge of the solution. The fewer players they have to deal with, the easier it is to control the distribution of medical care. This results in consolidation, monopolies, layers of management and regulation, none of which provide any actual care. However, expenses continue to increase before one patient is treated.
Resources are limited. Therefore, less should be spent on bureaucratic control. That is not likely, since history has proven otherwise. So, why not allow a parallel system to compete? There are doctors who are willing to risk themselves in the professional marketplace. The current system effectively does not allow it. The present health care market is not a free market. Doctors and patients are hemmed in by government policy (Medicare). If the patients want to contract with a physician outside of Medicare, the care prescribed (doctor visit, lab, x-rays, CT scans, etc.) are not reimbursable by Medicare. If the doctor accepts this contract with the patient, he or she will not be able to bill the government for any other Medicare patient for two years. Very few doctors can take that risk. The alternative to participation is dire, so the economic pressure is to join large organizations.
The systems that provide large institutional care (i.e. the VA, Kaiser-Permanente, ACO’s) have a place. The doctor as an employee is not new. What is new, and should concern all of us, who may need personal and compassionate care, is the lack of choice as to who employs our physicians. The institution or the patient? Along with the drive to provide universal health care, there should be a system that fairly and realistically leaves room for the individual practitioner. A doctor practicing independently, in a free marketplace, can provide professional services for a fraction of what a big box medical conglomerate has to charge. There should be room for patients and doctors to choose to contract for professional services and not be penalized. Choice in health care should be as universal as the availability of care.
|*From the files of CMS: |
HEALTH CARE FINANCING REVIEW/Fall 2000/Volume 22, Number 1; page 64
The following indicates the drama associated with this particular episode of Medicare managed care history. This is the text of the FBI international crime alert regarding the head of IMC: “In 1986, a federal government task force was established to investigate charges of corruption and fraud on the part of Miguel Recarey, Jr. Recarey was then head of International Medical Centers, America’s largest health maintenance organization. During its peak years, International Medical Centers received three-hundred sixty million dollars a year in U.S. government Medicare funds. In April 1987, the first indictment was returned in Miami, Florida, against Recarey and three co-defendants for conspiracy, bribery, obstruction of justice, and illegal wiretapping.” The IMC crisis for Medicare and for the Medicare enrollees of the organization was alleviated when Humana took over operation of the plan, which continues operating to this day. However, the image of Medicare HMOs was tarnished by the IMC experience for many years afterwards.
For the full report click here.
Note: Recary remains living in Spain today. The U.S. Government has not been able to extradite him.