Shift happens. That’s what a lot of worried hospitals, physicians, insurers (and probably patients) are thinking as they contemplate the uncertainties of health care reform. It’s like we’re all going to reform school together. Recently I pointed out that clinging to the status quo was going to take the nation down a black hole of rising national debt, unaffordable premiums for individuals and small businesses, and an unsustainable world of hurt.

As physicians, we’re already feeling that in all the price controls being slapped on the practice of medicine by all public and private payers happened before reform passed. The SGRrrr debate about whether or not to cut physicians another 21 percent in Medicare is a poignant and decade-long example of that.

With its warts and all, the PPACA (Patient Protection and Affordable Care Act) forces us into an environment of forced change. I hear a lot of grousing about it, but it’s here and it’s not going away. There are quite a few things we don’t like in the bill; and quite a few needed elements not included, but things have to change to expand access, to increase overall quality, and to align increasing costs to more closely track GDP.

Even if we don’t yet know precisely how that needed change should manifest to best accomplish those things, we still need to get at it. Importantly, as reform progresses we also need to make sure that we protect health research, science and innovation, which are significant contributors to the health of the American economy we can’t afford to undermine.

It’s all very tricky, and as I've stated before, there will be winners and losers. My question to each of you is: Do you know which you want to be? (Duh)

Hospitals are scrambling faster than doctors at present to build networks and prepare for integration. Not suffering apparently from ‘mural dyslexia,’ hospitals see the ‘handwriting on the wall’ as a need to change their game to prevent their bottom line from being slashed. PricewaterhouseCoopers broadly advised hospitals this week to prepare to promote continuous quality improvement strategies or risk severe upcoming penalties. PWC said appropriate hospital admissions, hospital-acquired conditions and payments tied to value-based care will be three key areas of focus on to remain profitable for both public and private care. 

Our own ACC cardiologist colleagues are already engrossed in a migration to hospital employment or contractual integration. Cardiologists are smart folks, and I do not see this as a migration of lemmings. But it may be an intermediary step leading toward different future structures. In California, for example, big news last week was that more than 20 major hospitals of Southern California have formed a foundation (with physician officers on the board) to bypass California’s “Corporate Bar on the Practice of Medicine” in order to create the equivalent of employed doctor networks. The Corporate Bar in California prevents hospitals from hiring doctors directly, so the new foundation model will hire doctors who will then exclusively contract with the organizing hospitals to provide care across the Los Angeles and Orange County region.

Wall Street investors believe that some of these changes were bound to occur with or without the PPACA and health reform. Medical students are not graduating aspiring to enter private practices, and would clearly prefer to be employed in groups or networks that minimize on-call, handle the administrative hassles, produce the flow of patients they will treat, and offer more control of their lifestyles. Meanwhile, hospitals and insurance companies, according to Wall Street, need to consolidate to reduce administrative costs and improve efficiencies. Thus, physicians will also need to consolidate or network to effectively negotiate with consolidated hospitals and payers. Health reform is just going to speed these processes up. A lot of these kinds of changes already have occurred in other industries. All of us recognize that such dynamic changes always produce winners and losers. 

Believe me, I recognize how difficult all this is to swallow for people out there who are taking care of patients, participating in reducing morbidity and mortality by 30 percent over the last decade, and working very, very hard to produce high-quality care now. You have to be asking, why do we have to endure this crazy process of massive change at the same time? There’s no easy answer. Change is tough, and unfortunately health care in this country, to be sustainable, has to change.

Hopefully we can make the changes necessary to ferret out the waste and ineffective aspects of the system and still produce the desired ongoing progress in science, quality, patient-centered clinical improvement and practice vitality. The risks really are enormous. The College has to be there as a partner with all of you as we go through these significant times of transition. But the opportunities are enormous as well.

*** Image from Flickr (worldsislandinfo.com). ***

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