We have heard the promises as the Affordable Care Act (ACA) was being sold to the public, including -- you can keep your doctor and insurance if you like it. We now know those promises to be mostly false as the ACA enters its fifth year of implementation.
Under the guise of "competition" and "efficiency," the ACA has unleashed a new round of disruption throughout the health care system. We are seeing further fragmentation of care, with less continuity of care with patients' physicians. The physician-patient relationship itself is at risk in a "system" increasingly headed for strangers taking care of strangers.
More than one-half of U.S. physicians are no longer self-employed and now work for organizations, mostly growing hospital systems but also some insurers that are moving into the delivery side of health care. Two examples illustrate the new landscape:
• Several hundred patients at the University of Pittsburgh Medical Center (UPMC) recently received certified letters informing them that they could no longer see their physicians. The reason: their insurance, Community Blue, sold by Highmark, is now both a rival hospital system and an insurer. Patients were cut off from their UPMC physicians even in the middle of cancer therapy. (1)
• United Health Group Inc. is the biggest player in the Medicare Advantage market with almost three million members and 350,000 physicians in its networks. In recent months it has dropped thousands of these physicians from its networks in at least 10 states. At Moffitt Cancer Center in Tampa, Florida, for example, some 2,500 current cancer patients will have to switch plans or find other physicians. (2)
A previous Health Care Disconnects post has described how patients are losing choice of physician and hospital through narrowing networks. (3) People can be in or out of a network at a moment's notice, a dynamic that almost certainly seems to be driven by money -- how can the insurer make more money by ridding its network of higher-cost physicians and patients.
Continuity of care, especially with a primary care physician, has been and should be the foundation of the physician-patient relationship. It facilitates coordination of care by other physicians and providers. But that continuity is now being split apart by market forces from all sides -- mergers and consolidation of hospital systems, business decisions of insurers, instability created by evolving accountable care organizations, shortage of primary care physicians, and the lack of inter-operability of electronic medical records, for starters. The challenge of how to coordinate and integrate health care in such a chaotic system increases by the day.
As the supposed signature domestic success of the Obama administration, we have already found that keeping your own physician and insurance plan is difficult, if not impossible. We will soon also find that health care is not more affordable, less expensive, or better with the ACA.
It is ironic that much of this could have been fixed before this latest round of health care "reform" kicked in with the ACA in 2009. Under a single-payer financing system, as embodied in An Improved and Expanded Medicare for All (H.R. 676), we could have a simplified, more efficient, not-for-profit public financing system coupled with a private delivery system, assuring all Americans with a comprehensive set of benefits and full choice of physician and hospital. President Obama recognized this as early as 2003 in this speech to the Illinois AFL-CIO:
I happen to be a proponent of a single payer universal health care program... (applause)... I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care [now 18 percent] cannot provide basic health insurance to everybody... A single payer health plan, a universal health care plan. And that's what I'd like to see. But as you all know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.
So much for talk, as he and his Democratic administration failed to follow through and deal with the corporate power of the medical-industrial complex. As we know, president Obama rejected single payer as "too disruptive" before negotiations started for reform, abandoned the public option during negotiations, and gave corporate market stakeholders even more opportunities to profit at patients' and taxpayers' expense.
The quest for profits under a business "ethic" of maximizing profits to owners and shareholders reigns over the implementation of the ACA, with no letup in sight. Don't count on electronic medical records to solve the continuity and integration problem -- many of these systems are customized to each institution, so that they don't talk well to each other.
Meanwhile, the patient-physician relationship, the traditional foundation of medical practice where continuity of care over years enables the best communication of needs within the narrative of patients' lives, is endangered. It can be rebuilt, but the trends resulting from the ACA are not promising.
1. Brown, T. Out of network, out of luck. New York Times, October 15, 2013.
2. Beck, M. United Health culls doctors from plan. Wall Street Journal, November 16, 2013: B1.
3. Gimlett, DM. Narrow networks: less choice, more cost shifting. Health Care Disconnects, posted September 12, 2013.