The Undeclared War on Private Practice

War is nothing more than the continuation of politics by another name.

Karl von Clauswitz (1780-1831), On War

Obama and his legions have declared war on private practice. It is an undeclared war.

It is a political war, waged in the name of humanity. It is like the war on cancer, the war on poverty, the war on women, the war of racism, waged in the name of greater causes for the common good.

By using the name “war,” you are showing your dedication and determination to wipe out the inequities plaguing humankind, or so you say.

You never officially declared a war. Your war is insidious, and it is political.

Many doctors, who cherish their autonomy and their freedom to exercise their clinical judgment, independent of government, see it as a war. If you doubt me, view Dick Morris’ video, “Obama’s War on Doctors,” sponsored by Money.

In his video, Morris, former adviser to President Clinton and no friend of Obama, invites doctors to describe the war.

Embattled bitter doctors, forced out of private practices, blast ObamaCare in vivid, often blasphemous language. They complain of low reimbursement from Medicare, Medicaid, and health exchange plans, of being compelled to install expensive electronic record systems, of having to hire extra staff to handle bureaucratic hassles and to feed data into computers, of being banned from setting up organizations of government preventing them from organizing their own competitive business organizations through self-referral and anti-kickback provisions.

Scott Gottlieb, MD, a practicing physician, scholar at the American Enterprise Institute, who has served in various capacities at the FDA and at CMS on medical technology issues, described the components of this undeclared war in a recent article in the WSJ “ObamaCare Threat to Private Practice.” Gottlieb said ObamaCare policies are forcing doctors to sell out to hospitals.

The ObamaCare strategy. claims Gottlieb, is simple and devastatingly effective, and it precedes him. Since 2003, when 70% of doctors were in private independent practice, today only 35% are, down from 49% in 2012 and 62% in 2008. The pace of physician-sell out to hospitals is accelerating.

How does the strategy to render private practice work?

1. It is a control not a cost issue. The government assume doctors on salary are easier to control than independent physicians, hence the ObamaCare strategy of placing doctors in Accountable Care Organizations on salary to coordinate care across the health care spectrum.

2. To prevent doctors from forming competitive organizations to compete with hospitals, you forbid them from gathering together in their own organizations, you stop them from referring to each other by saying you are preventing anti-kickback self-referrals.

3. You give doctors a lump-sum of money to care for patients in Medicaid, Medicare, and health exchange plans, which requires management and bureaucratic infrastructure to track and contol.

4. You allow hospitals to consolidate into larger and larger entities employing thousands and thousands of employees until hospitals and their systems become the dominant and largest employers in any given community, region, or state.

The hypocrisy is that in these large entities, self-referral within the system is a given. Salaried physicians within the system are obligated to refer to each other and to departments within the hospital.

Why is the large number of hospital employees so powerful politically? Because this employment base gives hospitals the leverage to negotiate with politicians. Hospitals argue that competing physician organization offering lower prices might cause them to downsize and lay off workers. This , of course, is anathema for politicians, whose job is to prevent unemployment. The incentive for hospitals is to buy more and more physician practices to further increase the number of employees, their market dominance, their leverage with politicians, and to decrease the threat of physician-market competition.

Because of regulations forbidding physician self- referrals with kick-backs and because hospitals can charge extra for “facility fees,” for visits or procedures done under the aegis of hospitals, physician fees are much higher for tasks done by salaried hospital physicians, e.g. heart scans ($749 versus $503), colonoscopies ($856 versus $402), and office visits $124 versus $70).

But never mind. Political control, not cost, is what counts in the undeclared war on physicians. It may also be one of the reasons why the original estimate of the cost of ObamaCare, $984 billion, is now $1.89 trillion, according to the latest CBO estimate.