In his OP-Ed in today’s WSJ, Dr. Scott Gottlieb makes several mistakes. I have time to address only three.
“ObamaCare is gradually making the local doctor-owned medical practice a relic.”
First of all, let’s stop calling it ObamaCare. That term is intended to be derogatory, largely borne of fear, mainly from the current Administration’s political opponents (such as Dr. Gottlieb’s employer, the American Enterprise Institute). Noble doctors realize healthcare reform should NOT be about politics, rather improving the access and quality of care for all Americans. PPACA isn’t making small fee-for-service (FFS) practices a relic, the industry’s and country’s macroeconomics are (see 18% GDP, see Steven Brill’s Time article, see Sequestration). Small, single-specialty practices don’t have the expertise, physician-leadership, or measurement / improvement infrastructure to eliminate the 35% of waste in America’s care (see recent IOM report). Only large, multi-specialty group-model practices can do that, like the Permanente Medical Groups.
“When doctors become salaried hospital employees, their overall productivity falls.”
Let’s provide the correct definition of ‘physician productivity’. It’s NOT “see the most patients per hour as possible”, rather “solve the most patient-problems per hour”, or if you prefer, “prevent the most illness, cure the most illness, resolve the most patient pain”. A given physician’s RVUs fall 25-35% following the transition from FFS to salary-based compensation PRECISELY BECAUSE 25-35% of the “care” in FFS (testing, drugs, surgery) is not medically necessary for the patients who experience it. It’s high time our entire profession define Physician-Productivity along the dimensions of patient outcomes (fewer illnesses, less need for hospitals, more cure, fewer mistakes). We’ve been doing it that way in the Permanente Medical Groups for 70 years.
“(Physicians paid a salary, rather than FFS will) no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.”
Money is a bad way to ensure doctors give their all for each patient. Measurement and Culture are the ways. When doctors are beholden to one another for quality, service, diagnostic and therapeutic excellence, their patients (and colleagues!) benefit. The purpose of paying physicians high salaries is to compensate us for working 70 hours a week, sleeping less than 4 hours many nights, and acknowledging our high-pressure, zero-margin-for-mistakes worklife, rather than to make money for the hospital (see my recent post entitled, “The Very Rational, albeit Regrettable, Link Between Profit and Salary in Healthcare”). Here’s the real reason practice acquisition failed in the 1990’s – once physicians no longer were self-rewarded to rack up excessive bills on their patients, they stopped. The acquisition companies were in it for the money in the 1990s (i.e., to receive the profits of overtreatment instead of the doctors). Had they been in the practice-acquisition game for the right reasons (to raise the quality and reduce the waste in care), we might not have needed PPACA 20 years later.
In fairness, Dr. Gottlieb gets two things right.
“When integrated delivery networks succeed, they are rarely led by a hospital.” True. They are led by humble physicians, grounded in the principles of evidence-based-medicine and continuous improvement, and experienced in effective leadership.
“(Most) hospitals aren’t buying doctors’ practices because they want to reform the delivery of medical care. They are making these purchases to gain local market share and develop monopolies.” True. I’m not defending the purchase of physician practices by hospital monopoles or oligopolies. And anyway, from what I hear, the FTC is gearing up to (finally) enforce our county’s Anti-Trust Statutes in this regard (let’s hope the FTC follows through on their duty).
So I guess this is my summary: Dr. Gottlieb’s editorial is more about earning his salary from his side of the political spectrum, rather than trying to inform the discussion of healthcare delivery reform.