Private medical practice in the United States is dying. I have personally watched its slow death in my 17 years as a private practice radiologist. Each new government intrusion into the doctor’s office—most recently with the Affordable Care Act—invariably adds costs, thickens red tape, and places new barriers between doctors and our patients.
Ultimately, these burdens encourage the centralization of health care at the expense of private practice—and our patients’ well-being.
What is driving this shift? Primarily bureaucratic hassle and incentive structures infected with government meddling.
Washington bureaucrats have already drafted at least 13,000 pages of regulations since the president signed the Affordable Care Act into law. This red tape—which requires physicians to fill out specific forms, document specific health patterns, and more—dramatically affects physicians’ daily routine.
Today, I spend twice as much time per patient filling out paperwork compared to when the ACA was passed in 2010. It would be one thing if that time was spent with the patient—instead it’s spent at the computer. Mandatory and redundant file keeping has become so time-consuming that our practice had to hire a full-time chief compliance officer (CCO). As any practice owner will tell you, CCOs don’t come cheap.
Medicare and Medicaid reimbursement rates are also problematic. Private practices are reimbursed less than hospitals for providing exactly the same service. The Medicare Payment Advisory Commission notes that while Medicare pays $98.70 for a 15-minute consultation at a hospital, it only pays $58 for the same visit at a doctor’s office. Our radiology practice is paid less for providing the identical services in our outpatient imaging center than the hospital is paid. Same service, same outcome, different pay.
These two factors—higher costs, lower pay—incentivize doctors to abandon private practice for hospitals and hospital-owned practices. Hospitals are simply better able to shoulder these and other administrative costs of health care in the post-ACA environment.
I am deeply concerned by this trend—and patients should be, too. The doctor-patient relationship is most effective at the private practice level. It encourages the personal, open, and forthright dialogue that so often contributes to better health outcomes.
It is understandable, then, that private practice’s decline has had a profound impact on how patients receive medical care.
First, the centralization of healthcare into ever-larger networks is limiting patients’ access to care. In 2012, the average private practice physician saw 22 patients per day, while hospital-employed physicians saw only 18. Extrapolated over the course of a year, each employed physician would see nearly 1,000 fewer patients annually than their private practice counterparts.
As more physicians flee private practice, patients may find it more difficult to schedule a doctor’s appointment. This tends to drive patients to seek care in the emergency room setting, which increases the cost of care.
Incentives currently built into the hospital and hospital-owned practice models are fueling physicians’ flight. Private practice physician incomes are dependent on the number of patients they see. Hospital-employed physicians, however, initially receive the same salary regardless of whether they see 20 or 50 patients a day. These incentives matter.
Larger practices may also bode ill for patient health. A recent study published in the health journal Health Affairs found that practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19, while those with 3-9 physicians had 27 percent fewer.
Most upsetting is that this death of private practice is no organic evolution of 21st century health care—it’s the intended result of the Affordable Care Act’s architects. Shortly after the law was passed in 2010, President Obama’s director of the White House Office of Health Reform wrote in the Annals of Internal Medicine that it will “accelerate physician employment by hospitals and aggregation into larger physician groups.” Unfortunately for patients, that’s one of the few promises they’ve actually kept.
The only winners—if you can call them that—of this centralized design are the bureaucrats in Washington who can assert more control over a shrinking number of health care providers. The losers are the thousands of private practice physicians being forced to abandon decades of hard work—and the millions of patients they used to treat.
Howshar is a radiologist based in Ft. Collins, Colorado and Cheyenne, Wyoming.