Uncertainty Defines Medicine

Physicians, Patients Suffer

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Commentary – January 2011

Tex Med. 2011;207(1):7-8.

By Louis J. Goodman, PhD, and Timothy Norbeck

"Uncertainty" is defined as the mental state of being undetermined, perplexed, vague, contingent, inconclusive, or in a quandary.

When it comes to health care, this is the state in which we find the majority of Americans today since the divisive debate over and ultimate passage of mind-numbing health reform legislation. The majority of private practice physicians in the United States share this uncertain state of mind regarding the viability of their medical practices.

Uncertainty freezes physicians' ability to make business decisions for their practices. For example, one provision of the Affordable Care Act assigns billions of dollars to a new vehicle called an accountable care organization (ACO). Hospitals, doctors, and payers will be enticed through enormous federal grants to join together in ACOs. (See "ACO Frenzy," December 2010 Texas Medicine, pages 18-25.) It doesn't matter that this kind of organization does not now exist, except in the minds of Washington bureaucrats.

The closest things to ACOs are long-standing medical group organizations such as Scott and White Clinic in Texas, Mayo Clinic in Minnesota, and the Cleveland Clinic. One glaring difference between these oft-cited outstanding organizations and Congress' concept is that these examples took decades to evolve from a very specific purpose that coincided with their founding. Scott and White was founded in 1897 to provide medical care to railroad workers. The Mayo brothers built their clinic in 1889 to treat the survivors of a tornado, and four respected Cleveland physicians established the Cleveland Clinic in 1921 in their desire to develop a then-new concept called a group practice.

Nevertheless, under the new health legislation, these unknown ACOs are supposed to do in less than five years what some of the best health care systems in the nation took a century or more to achieve. Yet, like the fate of many federal programs, ACOs seem to be on the uncertain pathway of spending billions of tax dollars with no tangible nor rewarding end in sight.

Physicians and physician groups continue to care for patients, but with the fear that tomorrow may bring new and unreasonable rules and regulations. Some believe these new regulations are well intentioned. Maybe they are. But the end result is that doctors are uncertain how or whether they will weather the storm. How can physicians invest in new technology that can streamline their practices, improve patient care, and reap financial bonuses if they don't know whether they can continue to keep their office doors open? And how can physicians compete on ACO ownership issues with large, deep-pocket hospital networks?

Medicare Fees Fuel Uncertainty 

Congress' inability or unwillingness to correct an unredeemable payment formula has brewed an enormous cauldron of uncertainty. What was once an annual charade that lured physician leaders to Capitol Hill to beg for relief from a pending Medicare payment cut recurred three times in 2010 alone. Who can keep a business alive, let alone plan for the future, against the specter of these on-again, off-again cuts in revenue?

 As former Medicare trustee Marilyn Moon was quoted recently in Modern Healthcare, "It's irresponsible that the health care law left such a major issue unresolved."

Uncertainty is manifested in the rapid and unprecedented interest in employment by a larger group or hospital, which is a significant change from the traditional private practice office. According to TMA's 2010 Physician Survey, three-fourths of young Texas doctors prefer an employed arrangement with an established physician practice, while only 22 percent would consider employment by a hospital.

Yet, both large and small hospitals and hospital systems are capitalizing on this uncertainty among physicians, forcing them to make hasty decisions on whether selling their practices is the only way to save their practices.

When a hospital or any other non-physician-based organization employs a physician, one must ask, Is undue and unfair pressure being placed on the doctor to conform to corporate mandates that may affect quality patient care? Unfortunately, the answer is probably yes. The TMA survey data show that physicians who choose to work for a hospital leave, on average, after three years; physicians who choose an established medical practice stay, on average, 12 years. Clearly, and to the patient's advantage, physicians value clinical autonomy to treat their patients appropriately regardless of the economic consequences foisted upon them by hospitals and encouraged by ACOs and other legislative aberrations.

Texas physicians use words like "disappointed," "confused," "anxious" and "angry" to describe their feelings about the law. A large majority of them believe that the quality of care will decline (77 percent) and the cost of care will go up (84 percent). Clearly, there is a significant disconnect between the makers of the law and the providers of care who are responsible for their patients.

Physicians are attending the Texas Medical Association's Health Reform Schools to learn about the new legislation. The schools, along with TMA's special online educational programs, provide venues for in-depth discussions about ACOs, health insurance exchanges, and quality, cost, and payment issues. Physicians must be educated about the legislation not only for their sakes, but also to answer the myriad of questions from their patients. Unfortunately, government help is almost nonexistent, and when a doctor's office does finally break through the red tape to ask a question, there is a good chance that the answer itself will be uncertain.

All of this uncertainty comes at a time when our health care system is in crisis. It comes at a time when medicine needs a good dose of American innovation and risk-taking. Uncertainty, instead, breeds stagnation and immobility. It is bad for medicine, bad for patients, and bad for our country.

Louis J. Goodman, PhD, executive vice president and chief executive officer of the Texas Medical Association, is president of the Physicians Foundation. Timothy Norbeck is the executive director of the Physicians Foundation.

Created by the settlement of organized medicine's class action lawsuit against for-profit HMO abuses, the Physicians Foundation is a nonprofit 501(c)(3) organization that seeks to advance the work of practicing physicians and to improve the quality of health care for all Americans. It pursues its mission through a variety of activities including grant making, research, and policy studies. Since 2005, the foundation has awarded numerous multiyear grants. Additional information about the foundation is available online.

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