The More Things Change …

Is private-office healthcare, as now practiced, in its death throes? Was the just-passed health reform legislation the final piece of a mortal trap that big business and government have been building for a generation, all to push out independent physicians to make way for bigger, fewer, and more easily regulated healthcare systems?

Yes, say many physicians.

Yes, say scholars, economists, consultants, and pretty much the entire healthcare industry intelligentsia.

No, says your humble editor. Or, more precisely: While a fundamental transformation in healthcare delivery is undeniably and unstoppably underway, I don’t think things for the average physician, when the dust settles, will be nearly as bad as many of you imagine. A lot of docs, in fact, will barely notice a difference and won’t care a whit.

A New World Order is emerging in American healthcare, and doctors are not at its apex. But were they ever? How long has it been since you felt like doctors were at the head of healthcare’s food chain?

In the healthcare world to come, you will have less control over how your practices are run, fewer of you will own practices or have partnership stakes, and you’ll be held accountable (if you aren’t already) to production benchmarks. You’ll probably have less freedom to make your own clinical decisions where evidence-based guidelines are in place. In exchange, you’ll get more income security and a more predictable working environment.

I think many of you who haven’t already made that bargain are ready to do so.

The arguments for a delivery system dominated by so-called accountable care organizations (ACOs), medical homes, or big delivery systems are well known. Healthcare will be more efficient. Cheaper. Better. Primary-care docs will be orchestra conductors for patients’ care teams. Everyone will have an interchangeable EHR, with patient records maintained in electronic depositories accessible to any authorized providers, whatever the place or time of service.

I know. Much of that sounds implausible. And to be sure it will take a long time to get all the way there, if we ever do. But healthcare policy wonks are perhaps more enthralled with the idea that the organizations providing patient care will be susceptible to more concrete changes - namely, incentives and penalties aimed at getting them (and you) to be more efficient, more productive, or just clinically better: We’ll pay you more if you use e-prescribing technology. We’ll pay you more if you see more patients. We’ll pay you more if you follow evidence-based guidelines.

That’s how they’ll put the A in ACO. It’s hard to imagine mom-and-pop docs’ offices thriving in that environment. But independent practices may yet have a role if they are large enough to compete on volume and/or function as an ACO contractor, nimble enough to work as an ACO subcontractor, or unique enough (because of a rare specialty, for example) that they can’t be left out.

Recently at PhysiciansPractice.com, my colleague Keith Martin hosted a live conference call with about a dozen physicians and Gregory Mertz, a consultant and occasional contributor to Physicians Practice, who wrote an article about physicians’ roles in ACOs. Mertz argues that ACOs will come to look a lot like a 1990s-style HMO, with the organization sponsor - a local hospital, in most cases - agreeing to accept financial responsibility for all of a patient’s medical care for a set period. The ACOs, seeking to contain costs, will strive to keep most services in-house, but most practices that aren’t owned outright by the hospital will serve as subcontractors in an ACO.

Doctors have been subcontractors since the dawn of health insurance. Much is changing in healthcare. Some things are not.

Bob Keaveney is the editorial director of Physicians Practice. Are you afraid that there won’t be a place for you or your practice in healthcare’s New World Order? Tell us in the comment field below.

This article originally appeared in the January 2011 issue of Physicians Practice.