What doctors should expect with health care reform

What should health care providers be doing in anticipation of the likely passage of an historic health reform bill?

There are at least three possibilities: (1) Lament the passing of the good old days and oppose it; (2) Insist that it isn’t good enough because it is lacking some key provision (tort reform; SGR replacement; robust public option); or (3) Embrace it, because incrementalism works, and prepare for what’s coming down the pike.

As you may guess, I would recommend taking the third approach, which requires focused preparation for the road that lies ahead. So, what is a provider to do?

In the future, there will be pilots, demonstrations and mainstream programs trying to do more with less: providing health insurance and health care services to more people, with effectively fewer dollars per capita. Payors — be they public sector or private sector — will therefore be squeezing providers. The House and Senate versions of the health reform bill are equally clear on this point.

Providers therefore need to be proactive in preparing themselves to provide high-quality health care services at competitive rates.Instead of simply resigning themselves to negotiating percentage discounts off of current rates of payment, all providers need to be prepared to negotiate global payments, pay for performance deals, quality incentives and more — as some forward-thinking provider organizations have been doing for some years now.

In order to be able to negotiate these terms effectively, providers must have a good handle on their own cost structure, and must begin to work at developing broader alliances of providers so as to be better positioned for negotiations with public and private payors.

In my years of experience in working with health care providers at that moment — the point in time when folks with otherwise disparate interests realize the tremendous value of working together effectively in order to simultaneously promote better clinical outcomes for patients and better financial outcomes for providers — I am always heartened by the epiphanies of the providers who realize that a new approach, or a new structure, can take them beyond their historical, positional, sometimes defensive attitudes, and into a future that they are able to shape and help define.

I look forward to working with more providers and provider organizations at this critical juncture so that they can be prepared for the future that will soon be upon us, and so that they can have a hand in crafting that future.

David Harlow is a health care lawyer and consultant who blogs at HealthBlawg.

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  • http://www.edwinleap.com/blog Edwin Leap

    Please understand that many of us, after years of struggling with government rules on billing, government rules on caring for the uninsured in the emergency department, government plans for making us ‘better,’ government safety regulations, government privacy regulations and all the rest have simply come to believe that the government’s answers are almost always inefficient, expensive, possibly dangerous and always inconsistent with the realities of life ‘on the ground.’ I know, it may be inevitable and we may have to adapt. But try to imagine comprehensive legal reform, in which government agencies and ‘legal insurance’ companies came in and told attorneys exactly how to do their jobs, and how they would have to learn to do those jobs with less resources, for less money and for more people. Sorry for the skepticism, but I’ve been on this train for a very long time, and I’m not feeling the love, no matter how much the president hawks it!

  • Sarahw

    Fourth option – reject it and begin again, with different philosophy and cures for present market distortions… not to, as you assert can be the only reason to reject it – to lament halcyon days of old.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    What Edwin and Sarah said.

  • David Allen, MD

    Edwin Leap and Sarahw both got it right.

    The suggestion here is that we simply roll over and get used to it. But it is not simply a small change or “key provision” that people (including many physicians) are concerned about. It is the attempt by politicians to put in place total control of the health care field I dare say, the government has almost accomplished this already – as they already spend 50% of all health care dollars. Medicine is one of the most highly regulated markets that exist – and the regulations occur an numerous levels and points in the ‘system’. It is amazing any creativity and efficiency actually occurs in the system at all!

    So forgive me but I DO LAMENT the direction things are taking. It is change in exactly the wrong direction, in terms of government control and financing. Why would anyone pretend to be happy with that? (Imagine someone unloading a pile of crap in front of you and telling you to have fun with it. Dig right in; help to craft it, arrange it how you like!)

    Health care ‘reform’ it is not a done deal yet – there is still time to fight. Even if the deal gets done, it can be undone. Laws can be gutted and repealed. Don’t give up the fight and become a jellyfish, as this author proposes!

  • http://drpullen.com Edward Pullen MD

    I can’t disagree that forming more integrated networks of providers to allow working together to provide better outcomes and create costg savings aounds like a good idea. The problem for many of us is that no such infrastructure exists in our community or evern region, and only trying to sell our practices (give our practices/) to some larger system would make this a possibility in the forseeable future. Should we all giuve up the concept of privately owned single speciaty groups and try to find a way to join an integrated system? In many cases we’d have to somehow coordinate the merger of innumerable small practices and create this from scratch. Seems insurmountable.

  • jenga

    Ditto Sarah and Edwin,
    I agree with #4) Reject it and either figure out ways to work outside the system (Cash Only) or leave the medical profession altogether, if our time and effort is no longer valued. No one is entitled to my work and practicing medicine is my choice, no one else’s.

  • Evinx

    What an horrific message for Americans in general and young people in particular! Can you imagine if the founding fathers of our country had the “Embrace it, because incrementalism works, and prepare for what’s coming down the pike” attitude? Let’s carry this thought further – if Lincoln had preached this attitude, if soldiers and military leaders had this attitude, if candidates for political office had this attitude (I guess Hillary would be president) — do I really need to go on?

    Many look at attorneys as “soldiers of fortune” in the courtroom – they like the fight but care little about who they are fighting for or the principles for which they are fighting. i believe the author’s mindset is demonstrative of this attitude.

    Very, very sad.

  • Doc99

    And then, there’s the Constitution.

  • Paul MD

    These are some of the most cogent, yet spirited and CORRECT responses that I have seen on this blog to the suggestions of Mr. Harlow. I am once again comforted that I am not alone in my thinking. Again, WE as physicians have NOTHING to apologize for.

  • Paul MD

    You confuse “heartened by epiphanies” with “wishful thinking of possible glimpses of hope.” Nice try.

  • http://healthblawg.typepad.com David Harlow

    Some of the comments posted to date are premised on the notion that the health reform legislation likely to be enacted in the near future is a bad idea. Reasonable minds may differ on that one, but it seems clear which way the train is headed. My point, at the moment, however, is simply that if change is coming, then physicians need to be prepared for it so that they can cut the best deal possible. (@Dr Pullen: Maybe this is the time to seek to organize physicians in your region into a new sort of entity, or under a new sort of umbrella.)

    The suggestion that the legal profession has not been subject to meddling by bean counters just isn’t true. The business of the practice of law has undergone significant transformation over the past several decades, just as the business of the practice of medicine has. Sophisticated purchasers of both types of professional services lean away from fee-for-service payment models and towards budgets, caps, risk-sharing, and appropriateness review of individual line items in bills. Large law firms in this country have collectively laid off thousands of attorneys and support staff in the past year; the more nimble service providers — legal as well as medical — are more likely to succeed in the current market.

  • http://healthblawg.typepad.com David Harlow

    @Doc99 Yes, the constitution: See http://j.mp/8YEt0Y

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Mr. Harlow, I appreciate the “heads up” to your follow-up comment on my blog: http://drjshousecalls.blogspot.com/2010/01/what-if-we-reformed-practice-of-law-in.html

    Here’s the thing. With the approval of lawyers, I was:
    (1) Told I was “not making enough money” for my “non-profit” practice (this despite covering 27/7 critical care back-up for EVERYONE in town); (2) Threatened to keep my mouth shut “or else” about BIG problems at the “Parent company” (hospital); (3) Fired for (A) ignoring those threats to go in and clean up another physician’s mess and save a life, then (B) reporting it to peer review; (4) Sued (unsuccessfully) for telling the government I served the truth about what happened (the government lawyers dived under their desks); (5) Swindled at settlement by CEO’s/their lawyers who withheld information that is public record; (6) (So far) blown off the the N.C. State Bar and the local DA/state Attorney General when I reported perjury/contempt/fraud. You see, I’m not “right people”.

    I don’t see ANY tort reform, whistle-blower protection or peer review reform in these healthcare reform bills – bills that I’m supposed to resign myself to – incrementalism I’m supposed to just accept as the way things are.

    Well, I’m almost 17 years into a career where NOTHING has turned out as I planned or hoped. I’m weary of “suits” telling doctors to just roll over and accept whatever is thrown at us. “Get over it”. “Move on”.

    And I’m black & blue from getting plowed over by the “train”.

    I hail from the land of John Edwards (don’t even get me started on the med-mal mess that is his legacy – especially for Peds and OB), so like “Dr. Leap” here, I’m definitely not feeling the love.

    I might be more “affectionate” towards reform if some of the lawyers and healthcare executives in this picture (the ones with the fat paychecks made on the backs of me and my patients) would doing some serious spring-cleaning in their own ranks . . . and if the government was capable of remotely decent oversight (it’s not) . . .

    . . . not holding my breath.

  • ninguem

    Some of the comments posted to date are premised on the notion that the health reform legislation likely to be enacted in the near future is a bad idea.

    Uh, yeah. I’d say that’s the notion. It’s shared by most of the country these days.

    Whatever we have now, everything……EVERYTHING……that is coming out of our legislature right now will make things orders of magnitude worse. Support is plummeting. Congress has had to bribe certain states to get them to sign on, surely you’ve noticed. No reason to bribe Nebraska, allow Medicare Advantage in Florida but not Arizona, on an on, if th reforms are so great.

    They will make things worse. So pardon me if I oppose current efforts and work to repeal the laws should they actually get passed.

    HSA’s now have five years experience in real practice. The data is coming in, they work, they really do “bend the cost curve”. So, naturally, they are being ignored in the legislation. Ignored at best, when they’re not taking shots at eliminating them entirely.

  • Ground Down FP


    The worrisome thing is we might NOT be able to repeal it. As per section 3403 of the Senate bill:
    Buried in Harry Reid’s massive amendment to the Senate version of Obamacare is Reid’s Section 3403 designed to prevent any future Congress from repealing a central feature of this monstrous legislation.
    “Section 3403 reads in part: “… it shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment or conference report that would repeal or otherwise change this subsection.”
    Do you think all the Democratic Senators understand the implications of this maneuver? If section 3403 remains in the bill and President Obama signs this measure into law, Sen. Reid intends that no future Senate or House will be able to change a single word of Section 3403, regardless whether future Americans or their representatives in Congress want to change it.
    The subsection at issue is the regulatory power of the non elected Medicare Advisory Board to “reduce the per capita rate of growth in Medicare spending.” It is an open ended grant to a regulatory agency granting power to control costs, quality and quantity of healthcare coverage.
    “And Reid wants the decisions of this group of unelected federal bureaucrats to be untouchable for all time”.
    Sen Reid compounds the problems of Section 3403 by ignoring two centuries of Senate rules. He passed the measure in the dead of night in less than 48 hours. Few Democratic Senators who voted for this bill have read and understood the implication of Section 3403.
    “The final Orwellian touch in this subversion of accepted procedure is found in the ruling of the Reid-controlled Senate parliamentarian that the anti-repeal provision is not a change in Senate rules, but rather of Senate “procedures.” Why is that significant?
    Because for 200 years, changes in the Senate’s standing rules have required approval by two-thirds of those voting, or 67 votes rather than the 60 votes Reid’s amendment received.”
    Few Democratic Senators have listened to the wishes of the American people. President Obama refuses to listen to the wishes of the American people.

    Best to oppose now because later may never come.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    I just looked up the Senate Bill online.

    Grounddown FP is right. Beginning on page 1001, in Section 3403, “LIMITATION ON CHANGES TO THE (INDEPENDENT MEDICARE ADVISARY) BOARD”, there’s some pretty disturbing language that would appear to prevent any future changes or appeals to the legislation:


    Resistance is not futile if resistance is now. It might be later on.

  • ninguem

    Ground down, and Mary…..understood.

    Reasonable minds may differ on that one, but it seems clear which way the train is headed……

    yeah. Off a cliff.

    I feel like a Pole with Molotov on one side and Ribbentropp on the other, a map of Poland on the table, and this lawyer counseling me to “get a seat at the table”.

    Pardon me if I don’t want to be part of the destruction of American medicine, if not the country itself.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    While we’re at it, has anyone seen this: http://overlawyered.com/2010/01/the-hidden-trial-lawyer-earmark/ ???

    More income streams for the lawyers – at the expense of doctors/hospitals/the public:


    On the other hand, gIven the dance-of-jurisdiction I’ve done as a physician-in-public-service-done-horribly-wrong (with no one in law enforcement thus far picking up the gauntlet on my behalf), I’m actually sitting here wondering if it’s something to support!?!

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