Health reforms planned to take effect over the next few years could accelerate shifts already under way in the health care delivery system, though the changes will be more incremental than dramatic, some in the medical field said this week.
"One thing about health care is, generally, change comes glacially," said Craig Becker, president of the Tennessee Hospital Association.
Some predict an increase in the trend toward hospital-employed physicians since small independent physician practices may struggle to cope with an influx of patients into the health care system and also with low reimbursements from public programs.
Physicians also may have to rely more on medical professionals such as nurse practitioners and physician assistants to treat patients.
Nationally, 16 million new people will be added to the public Medicaid program through an expansion of eligibility levels -- including 250,000 in Tennessee's Medicaid program, TennCare -- and that will be a boon to hospitals, since even the relatively low Medicaid reimbursements are an improvement over a total loss from uninsured patients.
Millions more will be required to purchase insurance coverage by 2014.
"Any time you create situation where the number of uninsured is cut by as much as three-quarters, the whole system is going to be working in a different way," said Karen Minyard, director of the Georgia Health Policy Center at Georgia State University.
Moves toward greater collaboration among providers are already happening, as providers try to cope with the economic recession, more uninsured patients and low reimbursements, said Darrell Moore, president and CEO of Parkridge Medical Center.
"I think we're seeing that evolution now. We're seeing physicians that are collaborating with hospitals on: How do we most effectively work together? What's more cost-effective?" he said. "With reimbursements declining, we all have to work together."
COST CONTROLS
Reform has been disappointing to some providers because of its large focus on changes in the insurance industry and improving access to coverage.
Not enough provisions addressed the need for reform in the fragmented and inefficient health care delivery system and underlying causes of rising medical costs, some local hospital leaders and doctors said.
"Probably physicians' biggest concern is that (reform) really does not do anything to decrease the cost of health care," said Dr. Pete Kelley, pediatric surgeon and medical director of business operations for University Surgical Associates in Chattanooga. "It just makes the system more readily available to everybody."
He fears that the resulting flood of patients into a flawed system will only fuel ballooning costs.
But Jim Brexler, CEO of Erlanger hospital, said the expansion of coverage will have significant benefits in its own right.
"If people aren't in a system of care with coverage, then there's no way to work with them to create incentives with doctors and hospitals to keep them healthy (and) to minimize the cost of their health care," he said. "If they're outside of coverage, then they use emergency room and we're spending multiples of what it should otherwise take to care for them, if we'd caught the disease earlier."
The Medicaid expansion worries some private practice doctors who fear that a flood of patients covered by a low-paying public program will make it harder for doctors to maintain their tight profit margins.
Ms. Minyard points out that reform provides a boost in payments for primary care physicians seeing Medicaid patients.
"It's going to be needed," she said. "We're going to need physicians to be recruited into primary care and to take care of the patients."
Dr. Bruce LeClair, family medicine specialist in Augusta, Ga., said he's hopeful about the impact of expanded insurance coverage and improved access to preventive care.
"It'll make my job easier," he said. "There are so many times I have to deal with patients that can't come in because they don't have insurance. ... Hopefully, it's going to be more efficient care. Maybe costs will go up in some areas and down in others."
CHANGES TO DELIVERY OF CARE MODEL
Some believe the new pressures on the delivery care system will necessitate some positive adaptations in the system.
Pilot programs in the reform plan try out a "bundled payments" model among some Medicare and Medicaid patients, in which all providers including specialists, hospital and primary care doctors, involved in one "episode of care" -- the days before and month following a health care episode -- are paid in one single payment. The set-up aims to encourage efficiency in care and better outcomes for patients.
Some physicians worry, though, that they could end up on the short end of the stick.
Looking aheadThe Times Free Press will examine the impact of health care reform in coming days.* Saturday: The cost to employers* Sunday: Pre-existing conditions* Monday: Coverage for young adultsREFORM PROVISIONS THAT AFFECT PROVIDERS* Expansion of Medicaid eligibility to those at 133 percent of poverty.* Incentives for small businesses to insure employees.* Subsidies for individuals to purchase insurance in exchanges.* Boost in payments for primary care physicians to care for Medicaid patients.* Unmarried adults up to age 26 can remain on parents' health plans.* Scaling back of disproportionate share payments to hospitals that treat the uninsured, based upon increases in patients with coverage.
"It sounds conceptually like it would be a good idea, but I think it's a devil-in-the-details type of thing," Dr. Kelly said. "You're going to have a single payment and multiple providers fighting over their portion of that payment."
Mr. Becker of the Tennessee Hospital Association said that, in Tennessee, particularly over the past year, there has been a movement of doctors in private practice toward hospital-based employment with the economic recession and payment cuts to TennCare making it difficult for their practices to remain open.
About 10 years ago, Memorial Hospital in Chattanooga began contracting with physicians to form what is now Memorial Health Partners, the hospital's physician group in which some physicians are employees of the hospital and some are still in private practice, said Jim Hobson, Memorial president and CEO.
The group is an early model of the type of partnerships that reform will likely foster between hospitals, doctors and other providers such as home health agencies, Mr. Hobson said.
"You'll see continued development of an integrated delivery system that helps make sure the patient is receiving the preventive care on the front end," Mr. Hobson said.
It's a prospect that alarms some physicians who prefer to work for themselves and who worry that salaried employment could erode the doctor-patient relationship.
"Not every doctor wants to work in a large group. They're fiercely independent," said Dr. Matt Smith, an OB-GYN in Dalton, Ga. "It's a little troubling."