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The Patient Protection and Affordable Care Act of 2010 has largely ruled the life of the average medical practitioner since it was signed into law by then-President Barack Obama in 2010. In the Summer 2013 edition of the Michigan Business Law Journal, Serene Zeni published an analysis of the impact of the ACA, entitled “The Business of Medicine for the Independent Practitioner Under the Affordable Care Act”1. The article warned the absence of a mechanism to protect the independent medical practitioner against the ACA’s increased regulatory burden combined with rapid change in reimbursement models would drive independent practitioners toward consolidation and hospital employment. This consolidation would, in turn, negatively impact access to and quality of care by reducing the number of independent medical practices disbursed throughout communities.
Recent data from The Physicians Foundation verifies the decline in independent practices.2 Since 2012, the number of physicians identifying as independent practitioners declined from 48.5% to 32.7% in 2016.3 The number of physicians identifying as employees of hospitals and medical groups increased from 43.7% in 2012, to 57.9% in 2016.4 Unfortunately, these trends exacerbate the concerns of reduced access to medical services and increased physician shortages.5
Physician attitudes toward the ACA as a vehicle for reform also became increasingly negative with 48.3% giving the law a grade of “F” and 23.3% grading it at “A” or “B”, compared to 45.8% giving the law an “F” and 25.4% giving it an “A” or “B” in 2014.6 These numbers indicate the growing concern that the ACA failed to gain the endorsement of physicians, which is necessary to achieve the law’s goal of transforming the healthcare care system from one based on volume to one based on performance.7
On Jan. 12, 2017, the Senate passed a budget that would effectively gut the ACA.8 This action along with the likelihood of the Republican majority in Congress and control of the executive branch resulting in the inevitable repeal and replacement of the ACA engendered fear over the loss of coverage for 22.5 million Americans who have Medicaid coverage because of the ACA.9 Studies confirm lack of insurance coverage has a negative impact on patient’s health and finances.10 However, multiple studies have been conducted to determine the impact of the ACA’s Medicaid expansion has not had a significant impact, despite increased coverage and utilization. 11
The decline of the independent medical practice is a key factor in resolving the dichotomy between the data confirming insurance improves health outcomes and the data highlighting Medicaid expansion under the ACA failed to improve health outcomes. Increasing access to quality care is a laudable goal. But to achieve that goal, the regulation must support the policy.
Regulation that trends toward consolidation, as opposed to integration of medicine, reduces the survival of the independent medical practice, which, in turn, negatively impacts health care financially and from a patient care perspective.12 From a financial standpoint, larger organizations mean more staff, more infrastructure and more administrative costs.13 The higher administrative costs are reflected in the higher rate of reimbursement hospitals receive, for example.14 Patients, in turn, pay for the increased reimbursement to larger employing organizations, as opposed to the small private practice, through their health care premiums and deductible plans.15
Health care reform cannot increase quality without accommodating for patient choice.16 The ACA has allowed insurance companies to escape participation from the exchange, narrowed networks, and made insurance negotiations substantially less flexible, leaving independent doctors incapable of obtaining adequate reimbursement to justify overhead costs and patients without choice.17 The inevitable outcome of the elimination of doctors from an insurance network was to cause patients to sever from their doctor, with whom they have had a long-term relationships.18 A 2014 review of 13 clinical studies highlighted that the integral value of a doctor-patient relationship in a patient’s health care outcomes.19
To successfully achieve the goals espoused by the ACA, health care reform, whether in the form of modification or “repeal and replace,” must cultivate the doctor-patient relationship, which necessarily means supporting the preservation of the independent medical practice as the change that is needed is largely desired by the majority of physicians – less regulatory burden, just reimbursement, effective incentivization toward clinical integration and quality outcomes and an emphasis on patient care.
1 Serene K. Zeni, The Business of Medicine for the Independent Practitioner Under the Affordable Care Act, The Michigan Business Law Journal, vol. 33, issue 2, pp 46 (Summer 2013).
2 Walker Ray, et al., 2016 Survey of America's Physicians: Practice Patterns & Perspectives, The Physicians Foundation, available at http://www.physiciansfoundation.org/uploads/default/Biennial_Physician_Survey_2016.pdf.
3 Id., at 19.
5 Id., at 42.
7 Id., at 43.
8 Thomas Kaplan, et al., Senate Takes Major Step Toward Health Care Law, The New York Times (Jan. 12, 2017).
9 JoAnn Volk, Get Health Insurance Through Your Employer? ACA Repeal will Affect You, Too, Health Affairs Blog (Jan. 11, 2017), available at http://healthaffairs.org/blog/2017/01/11/get-health-insurance-through-your-employer-aca-repeal-will-affect-you-too/.
10 The Kaiser Commission on Medicaid and the Uninsured, Key Facts about the Uninsured Population, The Henry J. Kaiser Family Foundation (Sept. 29, 2016), available at http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/.
11 Larisa Antonise, et al., The Effects of Medicaid Expansion Under the ACA: Findings from a Literature Review, The Henry J. Kaiser Family Foundation (Jun. 20, 2016), available at http://kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-findings-from-a-literature-review/.
12 See, for example, for discussion on consolidation v. integration, Joe Mott, Commentary: Consolidation without integration won't align incentives to improve quality of care. Modern Healthcare (December 19, 2015), available at http://www.modernhealthcare.com/article/20151219/MAGAZINE/312199978.
13 Reed Wilson, Why Private Practice is Dying, Forbes Magazine (Sept. 7, 2016), available at http://www.forbes.com/sites/realspin/2016/09/07/why-private-practice-is-dying/2/#74lffe394da2.
16 Kevin Campbell, The Impact of Obamacare on the Doctor-Patient Relationship, US News & World Report (Jan. 25, 2016), available at http://health.usnews.com/health-news/patient-advice/articles/2016-01-15/the-impact-of-obamacare-on-the-doctor-patient-relationship.
19 John M. Kelley, et al., The Influence of the Patient-Clinician Relationship on Healthcare outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, PLOS One (April 9, 2014), available at http://dx.doi.org/10.1371/journal.pone.0094207.
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