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COMMENTARY


Is bigger better? BY LOUIS J. GOODMAN, PHD, AND TIMOTHY B. NORBECK Who


would deny that health care is big business? It is also the most personal of all human endeavors. Why then does the federal government appear to be in such a rush to depersonalize our medical care?


“Bending the cost curve” seems to be the driving force be- hind the recent health care reform, especially in light of the fact that national health expenditures have doubled over the past decade from $1.3 trillion in 2000 to $2.6 trillion in 2010. And the Af- fordable Care Act rewards hospital systems at the expense of small and solo, personally-oriented medical practices, under the mistaken theory that bigger systems are, or can be, more cost-effective. Where was the voice of two of the most important constituencies in these discussions: patients and prac- ticing physicians? The answer: Their voices didn’t matter to the reformers. There was a time when physicians and their patients worked together to determine what was best for the patient. Such participation has been ceded to the federal government. The question of size may well be the most important aspect of the congressional overhaul. More than 80 percent of personal medical care services are provided in the doctor’s office, and less than 20 percent of services are provided in the hospital.


Why should health care delivery remain in the doctor’s of- fice? Because it is the most cost-effective setting to receive health services. Medicare says the average visit to the doctor’s office costs $61, compared with the cost of an average visit to the hospital of $10,908. Why then is Congress pushing as many services as possible


to the hospital through consolidation, merger, acquisition, and shared savings programs? If the hospital is the most expensive


It is all


about control; unfortunately, practicing physicians and patients


place to provide care and the physician’s office is the most cost-effective place to receive care, why has Congress moved care away from the doctor’s office and into a hospital waiting room? The answer appears quite evident: Congress and the Execu- tive Branch believe that a Canadian-style single payer system is where health system reform will rapidly evolve our current system. Here is the evidence. First, the government’s share of our national health care bill, which was 44 percent in 2000, was project- ed to be 50 percent in 2010. Or more aptly stated, the government’s share of national health care expenditures has doubled over the past decade, from $596 billion in 2000 to $1.3 tril- lion in 2010.


don’t have any!


Second, hospital systems are get- ting bigger and in many markets, they exercise monopoly power. For example, the Texas attorney general filed suit against a large Houston- based health care system alleging violation of state antitrust statutes by unreasonably restraining competition among acute-care in-patient hospitals. Third, physician practices are evolving from predominantly solo practice to four or five-doctor groups to remain economically viable. Large hospital systems are rapidly gobbling


up small hospitals, and large health insurers are purchasing small insurers, further eroding what little competitiveness re- mains in the market.


The consolidation of the American health care system is fol- lowing the path of banking, telecom, and, most recently, the American automobile industry. The health system reform law in many ways is modeled after the Canadian national health system, with centralized government planning power as the dominant feature. But similarities between the United States and Canada stop there. Most physicians in Canada are private


July 2011 TEXAS MEDICINE 5


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