Now that the ACA will become a certain reality, the two areas that interest me most are beginning to come into focus out of the mist. One has to do with how the quality and availability of healthcare will be affected, while the second is about how the practice of medicine by physicians will change.
The evolution of all this will start out slowly and then become an avalanche by 2017 as new regulations come into play. At this time, there is no way to be certain about much of the details, because the ACA is, in large part, largely a skeletal plan waiting for the blanks to be filled in. There are many complicated aspects to all this, so let’s consider some of what will happen to physicians and the doctor-patient relationship.
It is clear that there will not be enough primary care doctors to meet the needs of all the patients that will be served in the future. Care will be given by teams of providers, supervised by doctors who delegate tasks to all sorts of physician extenders like nurses and PA’s. The doctors will no longer have a personal relationship with patients. The care will be largely governed by practice guidelines, and the physicians will just be a cogs in big wheel complex care systems. Most doctors will be employees on salary, and their life style will be easier than in the past. Fee for service reimbursements will disappear as will the private practice of medicine by solo or small group practices.
Here are three indicators that I have observed recently by talking to three physicians.
Doctor A is a solo internist who has been in practice for about 10 years. He is 42 years old and he is loved by his patients and highly regarded by his colleagues. He has just announced that he will soon close his practice and seek work in some type of large scale setting like the VA or for a hospital organization in some sort of clinic setting. The reason is economic: declining reimbursements and rising costs have caused his “business” to fail.
Doctor B is a 52 year old cardiologist who is a superb clinician and consistently is mentioned in the “best doctor” listings. He worked hard to be accepted into training at one of America’s finest medical centers. His hours are long and exhausting. He and his colleagues have formed a large group practice, but he cannot keep up with the rising demand for his services accompanied by sharp declines in reimbursements from providers such as Medicare. Recently he stopped taking new patients. He says that morale is low among his colleagues because they see no way to pedal faster while maintaining quality and income. He tells me that I “got out just in time,” and he is looking forward to an early retirement.
Doctor C is a 3rd year internal medicine resident at a city medical center. He tells me that half of his fellow residents will go on to become specialists. Another quarter are seeking salaried hospital jobs. Those “hospitalist” doctors work 7 days on and 7 days off. The final quarter are seeking jobs in outpatient settings, but almost none of them are planning to open their own practice. He and his fellow residents fully expect decent pay in exchange for a better life style. Doctor C is satisfied with that conclusion. Out with the old and in with the new.
Most practicing doctors today are feeling discouraged about the prospects for their profession. As for the quality of care that will evolve, I believe it will deteriorate when judged by traditional standards, but the public will blindly accept its fate as our system is changed forever. Stay tuned.