Life post-Patient Protection and Affordable Care Act

ByDavid M. Glaser, JD

If you are disappointed by the Supreme Court’s ruling upholding the Patient Protection and Affordable Care Act, don’t be. If the Court had ruled that the purchasing mandate was unconstitutional, then the impact on your day-to-day life would likely have been immeasurable.

I am not suggesting that it is unreasonable to be frustrated with the practice of medicine today. But the issues are larger than, and mostly independent of, the Patient Protection and Affordable Care Act (PPACA). Over my lifetime, the same basic tensions have affected the delivery of health care. There are concerns about increasing cost, preserving freedom of choice, maintaining access to both the system and to new technology and improving quality. The conflict between controlling costs and the other three factors is constant.

HMOs were one high-profile outgrowth of the desire to contain cost, with a claim that capitated payment would also result in higher quality. While HMOs were created during the Nixon administration and authorized by specific federal legislation, the main driver behind their expansion was the desire of businesses to reduce health care costs. The market, not the law, was the main driver. ACOs are merely a new label for the same idea. Business and the government are still seeking ways to control health care costs. Whether the PPACA survived or not, the market will continue to develop variations on the theme.

Autonomy

I believe that autonomy is a major determinant in happiness for most professionals, and particularly for physicians. When a physician feels he or she has control, job satisfaction increases. Declining reimbursement, the bureaucracy often associated with large organizations and increased governmental regulation may lead physicians to a feeling of helplessness. It is true that PPACA creates some new regulation, but that regulation was not in play in the Supreme Court case. In other words, the decision is not a “loss,” nor would the opposite decision have been a victory.

If you are feeling discouraged, I would encourage you to recenter on a key point. The single most essential factor in the health care system is the physician. Whatever change befalls the system, physicians will form the bedrock. It is quite possible that integration will continue. But that doesn’t mean physicians must surrender autonomy. Physicians can, and should, run the integrated systems. Many of the most successful health systems are physician run. A desire to contain costs will result in a constant stream of new rules and directives. Some of those directives will come from the government, others from insurers. But the American public places a very high value on freedom of choice and access to professionals and technology. They also trust physicians. Patients should be a powerful ally as you prepare to parry the attacks.

Physicians have historically struggled to speak with one voice. Tensions between primary care and specialists, between subspecialties and even within specialties are common. On a practical level, you face another significant challenge: you spend your day seeing patients. Time you spend on any administrative function is “lost time.” By contrast, large organizations, particularly hospitals, have administrators that can take the time to travel to the nation’s capital to testify on a bill. Physicians are reluctant to give up the time. This means that you start off with significant disadvantage in most public policy fights. Other players have more time, and often more resources. But you can counter that advantage by using your power as a health care provider.

Positive energy

If you are feeling despair at the result of case, I would suggest you try to convert that to positive energy. Reach out to fellow orthopedic surgeons, or to physicians in other specialties, and brainstorm about how you begin to assert more control. If you all banded together, could you form a physician directed integrated system? While it is true that the Stark Law prevents the formation of for-profit hospitals, a non-profit model can allow you to maintain autonomy and still earn a very reasonable living.

Consider a divisional merger – a great way for physicians to join together while still preserving individual autonomy. For more detail on this, see the March 2011 Orthopedics Today Round table “Current medical malpractice litigation: Proposals for reform.” Find a way to make sure you are monitoring and influencing the debate in your state legislature. And remember that while the PPACA may seem like a good scapegoat, that is all it is. The good news is that laws will come and go, but physicians are the keystone to the health care system. It may be time to remind people of that.