At first, the decline was subtle. In the 1980s, Medicare imposed price controls upon physicians who treated anyone over 65. Providers were required to use a coding system to describe the service when submitting a bill. The regulators believed that standardized classifications would lead to more accurate processing of Medicare claims.
I am a general surgeon with more than three decades in private clinical practice. I have watched my profession slowly evolve into the domain of technicians, bookkeepers and clerks.
Instead it made doctors and hospitals wedge their patients and services into predetermined, ill‐fitting categories. Medicare has used this coding system to maintain its price controls for more than 20 years. Private insurers, starting in the late 1980s, began pegging their compensation contracts to the Medicare code‐based fee schedule, effectively extending Medicare price controls into the private sector.
Today, most doctors in private practice must employ coding specialists, a relatively new occupation, to oversee their billing departments.
Private insurance carriers addressed rising health care costs by creating the health maintenance organization (HMO). Strict oversight, rationing and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top‐down regulations were set aside and many HMOs were watered down into little more than expensive prepaid health plans.
With the dawn of the 21st century, Medicare imposed protocols and regimentation on America’s physicians through a centralized bureaucracy. Using so‐called “evidence‐based medicine,” these protocols are based on statistically generalized — rather than individualized — outcomes in large population groups.
It is easy to standardize treatment protocols. But it is difficult to standardize patients.
Patients should worry about being fit into standardized clinical models that ignore the vital nuances of their complaints. Even more, they should be alarmed that the protocols being used don’t provide any measurable health benefits. Most were designed and implemented before any objective evidence existed as to their effectiveness. Ironically, the protocols are not “evidence based.”
The “stimulus” act of 2009 requires all physicians and hospitals to convert to electronic medical records (EMR) by 2014 or face Medicare penalties. Again, no peer‐reviewed study had shown any major benefits from such a conversion.
Price controls have coincided with a steady ratcheting down of fees for doctors. Meanwhile, Medicare’s regulatory burdens on physician practices continue to increase, adding on compliance costs. For many physicians in private practice, the costly EMR requirement is the final straw. Doctors are increasingly selling their practices to hospitals, thus becoming hospital employees. The doctor‐patient relationship becomes adversely affected as doctors come to view patients as the hospitals’ patients rather than their own.
By 2011, fully 50 percent of the nation’s doctors had become employees — either of hospitals, corporations, insurance companies or the government. As economic pressures on private clinical practice continue to mount, we can expect this trend to accelerate.
For the next 19 years, 10,000 Americans will turn 65 every day, increasing the fiscal strain on Medicare. ObamaCare attempts to deal with this partly by reviving an old concept under a new name: Accountable Care Organization (ACO), which harks back to the infamous HMO system of the early 1990s.
Put simply, hospitals, clinics and health care providers are organized into teams that will get assigned large groups of Medicare patients. They must follow practice guidelines and protocols approved by Medicare. If they achieve certain benchmarks established by Medicare, they get to share a portion of Medicare’s savings.
If the reverse happens, there will be economic penalties. Private insurance companies are following suit with non‐Medicare versions of the ACO. In both the Medicare and non‐Medicare varieties of the ACO, cost control and compliance with centrally planned practice guidelines are the primary goal.
Stealth rationing will be the result.
Once free to be creative and innovative in their own practices, doctors are becoming more like assembly line workers, constrained by rules and regulations aimed to systemize their craft. ObamaCare has put the medical profession’s already bad trajectory on a worse path. It’s no surprise that early retirement is starting to look more attractive.
Many of my generational peers in medicine have gone part‐time, taken early retirement or quit practice and gone to work for hospitals or as corporate consultants.
Some are starting cash‐only “concierge” medical practices that accept no Medicare, Medicaid or private insurance. As old‐school independent‐thinking doctors leave, they are replaced by protocol‐followers.
Medicine, in just one generation, is transforming from a glorious profession into just another rote occupation. This affects us all — because we will all be patients someday.