Failed Promises of Corporatized Healthcare

I did not attend this conference. I first saw this slide on Twitter, and it struck a nerve. “No clear evidence about costs, quality, patient experience.” This is not only insulting but unequivocally false. I am a Direct Primary Care Physician. I ran a successful solo fee for service practice for 11 years until my salary became similar to what I could make as a cashier, dropping sharply every year following the implementation of the Affordable Care Act (ACA). Most people will think I am exaggerating. I am not. Thankfully, I am not driven by money. It is a necessary ingredient to running a financially secure medical practice, but at the end of the day, I am driven by my relationship with my patients. These connections are what I enjoy most about being a doctor and being an independently practicing physician is the only way I see to preserve the integrity of the physician-patient relationship. So, when faced with the prospect of closing my practice to join corporate medicine, I realized I would leave the medical profession before I would become an employed physician in a corporately owned medical group. Thankfully, I was introduced to Direct Primary Care (DPC) where costs are contained and transparent, quality care is regularly delivered, and patients are not only satisfied, but delighted.

The decline of the modern health care system and that of the independent solo and small group practices began with the creation of HMOs in the 1970s. The implementation of the Affordable Care Act (ACA) put the proverbial nail in the coffin of independent practices, particularly those providing primary care. Fewer than 18% of primary care physicians were in independent practice at the end of 2018 compared to 43% in 2012.  This trend is mostly due to regulations within the ACA that are focused on population health and value-based payments that put larger practices in a better position to negotiate reimbursement rates and to spread the costs associated with regulation compliance across many clinicians.  This legislation creates enormous pressure to consolidate independent practices, causing many to sell their practices or join an Accountable Care Organization (ACO), groups that have become the primary delivery mechanism of corporate style medicine and the home of the 7 minute face-to-face visit with your doctor.

Initially, ACOs promised better outcomes through a team approach and the implementation of expensive integrated clinical information systems that would presumptively coordinate care. However, thus far, the ACO concept has mostly failed. It has failed both financially and ethically. It failed physicians by creating a system that undermines physician expertise by creating the illusion that less costly NPs and PAs are equivalent in clinical training to physicians and by diminishing the value of individual physicians by considering them easily replaceable employees. It failed the American public by directly driving up consumer health care expenses, resulting in a negative effect on population health and patient satisfaction.

Often ACOs monopolize local health care markets, leading to a significant decline in the number of independent, cost-effective options for not only medical care, but also ancillary services such as radiology and laboratory testing, resulting in consumer price fixing. Furthermore, people who receive their primary care from ACOs are more likely to be referred to specialists within the ACO for diagnoses primary care physicians are fully trained to manage, causing the consumer additional out of pocket expense that further enriches the ACO. It is also in the participating physicians’ interest to appropriately refer to specialists within the ACO as this, too, benefits the ACO financially. Additionally, by corporatizing the healthcare delivery system, there is excessive, wasteful spending that these organizations must recoup directly from the consumer, including multi-million dollar start-up costs, the bloated payroll and benefits of administrators, middle managers, and excessive staff members, and the expenses incurred to support the organization’s large infrastructure.

Most importantly, people receiving care through large groups (defined as more than ten physicians) have higher rates of hospitalization for preventable causes than those cared for in small independent practices. The experts have surmised this is due to the dissolution of the traditional doctor-patient relationship and inadequate access to care in ACO and other large group practices. The average wait time to see an ACO employed PCP is 29 days, which often delays care and results in worse outcomes. One way small independent practices and their patients are thriving is through Direct Primary Care, an affordable open access model that is not only containing costs, but most importantly improving patient care.

Direct Primary Care (DPC) offers affordable, transparent pricing and significant cost savings not only on health care, but also on ancillary services for the consumer. DPC practices charge a small monthly fee in exchange for primary care services and do not bill insurance for in-office or virtual visits or most primary care procedures. Practices vary regarding price and included services and procedures, but at the heart of this model is open access to your physician for urgent medical issues through same day appointments and after hours availability. It is this direct access to immediate care and the restoration of the doctor-patient relationship that leads to better outcomes.

Concierge practices may offer similar benefits; however, in contrast to DPC, Concierge practices typically charge a significantly higher annual fee and bill insurance carriers for any services rendered.  At least the speaker is aware there is a difference between DPC and Concierge Medicine. Whether this concept was presented accurately, I cannot say since so many “experts” in health care policy are still struggling to understand the DPC model.

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Cynthia R Stuart DO

Dr. Stuart is Board Certified in Family Medicine. Originally from Georgia, she spent most of her youth in Miami, Florida and has been a Texas resident since the early 1990s. She attended UNTHSC-Fort Worth and completed her residency at UTSW/Methodist Hospital System where she was Chief Resident in her senior year. She is an Associate Professor at UTSW and UNTHSC, participating as a preceptor for medical students and residents. She completed a two-year course at SMU Cox School of Business in Advanced Leadership that enables her to advocate for quality health care providers and local public health programs in her community. She is the head of the Credentials Committee, sits on the Medical Executive Committee and the Ethics Committee at Baylor Scott and White Hospital of Carrollton. She has appeared on numerous news and radio programs to educate the public about various health topics. Dr. Stuart has managed her private practice in Carrollton since 2005 and is now a Direct Primary Care Physician. 

  2 comments for “Failed Promises of Corporatized Healthcare

  1. Seneca
    May 16, 2019 at 8:41 am

    For reasons you described, I have been surprised that there has never been a federal investigation into anti-competitive/monopolistic practices, antitrust issues and frank price fixing by large corporate health groups who operate as virtual monopolies in some markets.
    All their resources and it takes 29 days to get a PCP appointment? If they actually have any sick people in their panels, it would be interesting to know the mortality of that.

  2. Pat
    May 16, 2019 at 7:50 am

    Excellent points. Pity that the majority of voters believed the ACA BS, and cannot grasp what you effectively outlined.

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