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Wednesday, February 6, 2013

Unintended Consequence of the Affordable Care Act

 

The scenario: As written in the WSJ by David Lefffel M.D. (Yale University)

The Doctor's Office as Union Shop

Doctors have always been loath to strike, feeling a moral sensibility as to responsibility for their patients. And on a practical standpoint…the physician is the key producer in a medical business. Any type of work stoppage would be a self inflicted suicide gesture, for there is little wiggle room anymore in health financing.

Any strike would be self-limiting, short duration and largely a gesture as to physician discomfort with the evolving changes wrought by the Affordable Care Act.

As the country moves toward the effective start date of the Affordable Care Act in 2014, the operational and economic elements of this vast legislation are becoming clearer. Yet one likely outcome of the act that will directly affect the quality of patient care, and could affect its cost, has gone virtually unnoticed and unreported: the increasing trend for physicians to become employees, rather than self-employed. This development represents a potentially radical factor in the transformation of health care—the doctor as union worker.

Unlike hospitals, which operate under the rubric of large regulatory agencies, physicians have been much more difficult to regulate and monitor. For cost control to be effective, the professional autonomy and independent clinical judgment of the physician and other providers must in some measure be sacrificed to standardization. This can't be accomplished by overseeing thousands of doctors in thousands of offices and medical complexes, each conducting its own symphony.

The Obama administration, by intent or accident, has effectively driven a major change in the status of physicians. By reducing the reimbursement for certain office-based specialists while enhancing related payment to hospitals, the administration is compelling more and more physicians—many of them with an any-port-in-a-storm fatalism—to seek employment with health systems or large physician groups.

The change in the nature of physician employment will have effects never before experienced in America. As the effects of the Affordable Care Act come into focus, it becomes clear that when the majority of physicians are no longer self-employed—and barring any legislation to the contrary—their new employed status will provide doctors with the right to collective bargaining.

Leaders of the organized-labor movement already view service workers with nonexportable jobs as the last best hope of labor unions whose membership is at an all-time low. The truth is that physicians are now becoming service workers. They are well-educated and expensive to train, and their decisions have substantial significance in the lives of others. But doctors essentially provide a service, one that cannot be outsourced to India or China.

f doctors unionize, that raises an immediate question about their right to strike—the key lever in collective bargaining. That's a question for another day. For now, it's enough to contemplate what will occur when the practice of medicine becomes detached from its past as a profession—when doctors may in time come to see themselves not solely as healers but as workers, units of labor, in a system that is committed to delivering care to the greatest number.

When doctors occupy a service niche like the chambermaid in Las Vegas or the school teacher in Chicago, the expectations and compensation of the physician-worker will be defined in ways that may make the benefits of collective bargaining appear very attractive.

As has happened in other countries that have charted the course we are now on, a new reason for lack of access may at times be: "Office closed, doctors on strike."

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