I thought that I would look at what the Affordable Care Act would do to physician’s practices. With the increasing proportion of Medicaid patients, which pay the physicians some of the poorest reimbursements, especially for surgeons and specialists, physicians wonder how they are going to pay their bills. So, what are physicians to do? The overhead of the practice continues to rise, including computer hardware and software (necessary to bill the insurance system) and the malpractice premiums, more and more of the doctors are considering strategic options in order to practice and follow their dreams- to care for sick patients.

How can they do this? How do they pay for their education loans, their malpractice premiums, borrow more money to start that ideal goal of starting their practice to treat every patient that needs our time and care?

Reading other blogs it is amazing how delusional people are thinking that physicians must treat patients, no matter their ills, ability to pay or whether they will be compliant. In other wise even if we care for them, will they care for themselves, take their medicines, loose weight, diet and exercise. Preventive care is always cheaper and more effective than interventional care.

The future of medicine is in question! More and more of the potential medical students are considering the return of their investment. They are choosing other professions including nursing, dentistry, business and engineering.

Those that are still convinced that their calling is medicine are looking at other strategies to survive and deliver health care. Remember, physicians go into medicine, or used to go into the profession of medicine because they want to make a difference, and it is the daily opportunity to help patients that keeps many of them/us going. Yet today many worry that their contribution is diminishing, and more and more physicians are reporting burnout. Many factors are responsible: increasing productivity demands, decreasing amounts of face time with patients, and a growing awareness that they are spending more time on activities such as record-keeping that don’t enhance their patients’ health.

So, what options do they have and does it fit with the Affordable Care Act (ACA)?

Many physicians are choosing the more common option of becoming employees of a hospital and or large health care system such as MedStar, Humana or Kaiser Permanente. In this type of strategy the physician “negotiates” their salary, loan repayment and malpractice premiums. Their malpractice premiums, as part of a larger insurance umbrella, are usually cheaper. They get paid their salary checks but there are bonuses and penalties for performance or lack of performance. This creates a very non-personal doctor-patient relationship allowing for shorter and shorter patient visits and longer and longer wait times as I have stated in past blogs.

A good number are at least considering and many are transitioning or shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a consulting company that help physicians make such shifts, they will cease caring for their many thousand patients and instead cut back to about 500-600 patients. These patients will pay an annual fee of between $750 at the lowest end to $5,000 at the high end. In exchange, they receive a one to two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.  

When patients get admitted to the hospital, the concierge doctor will remain their physician, and their health insurance will still pay for much of their care.  Will it make more money for physicians? Most physicians doubt it, but if it does, they usually plan to reinvest any additional income they might derive back into their practice, helping to lessen the economic pressures. This allows the practice to limit their practices to manageable numbers so that more time can be spent with their patients. This type of practice model should “guarantee” better care for the patients and a greater fulfillment for the physician.

The problem with a concierge model is that it creates a two-tiered health care delivery system. But is this new? I believe that we already have a two or three-tiered health care delivery system and that the ACA will only insure that this multi-tiered delivery system will persist

The third option is a hybrid system as we see in the British health care system. This is where the physician is a part time government employee and then has a private concierge practice in the afternoon in their private clinics. This system seems to work for those that have the money to pay for their health care. What about those patients that can’t afford to pay out of pocket for efficient, caring, exceptional health care? Or does the concierge or hybrid models guarantee the best delivery model for health care?

Interestingly enough this system is more applicable to the non-primary care physician. The specialist, surgeon, etc. really can’t have a concierge model because they depend on their referrals from the internists and primary care physicians for their patients.

I will discuss the concierge model in next week’s blog as I review the case for the concierge health care delivery model.

Once again I pose the question-do you really know what the new ACA system will eventually become and whether it is really better than what we have or had before the start of the ACA?