A battle is being waged for the heart and soul of medicine.
No, it is not the stagnation and partisan bickering in Congress or the fierce health refom battle before the Supreme Court.
It is more like a deadly cancer, quietly and slowly growing in our government, threatening to take away local control of hospitals and stifle input from independent physicians and providers.
It is estimated that by 2013 more than two-thirds of physicians will be employed by or have a contract with a hospital.
Hospitals are paid more than free-standing surgery centers and independent physicians for delivering the same outpatient services. Eighty percent more for mid-level outpatient doctor visits, says the Medicare Payment Advisory Commission.
There are similar discrepancies in procedural payments between hospitals and free-standing surgery centers. Medpac is trying to reverse this Medicare money loss, but the damage has been done.
Low-paying practice incomes have forced physicians into hospital employment in droves, resulting in the loss of the independent medical staff at hospitals.
It has long been accepted that physician ownership of a hospital represents a conflict of interest, and regulatory safeguards have been instituted; but few safeguards exist for the hospital ownership of a physician practice, despite a similar conflict of interest.
You may be sitting in a small country doctor's office far away from the main hospital, but if the contract has been signed and the office is now a hospital facility, you will probably be billed an additional fee for use of the facility, similar to a cover charge.
If you need a major test or to see another doctor you will probably be referred to the parent institution.
Inadequate safeguards exist to protect doctors from retaliation if they refer a patient to a different hospital or an out-of-network provider.
The primary loyalty of a physician should always be to the patient and not to an employer. Patients expect this, and requirements for future health care delivery systems should clearly state it.
Regulations have been proposed to clear the way to dissolve community hospital boards, allowing a single board in a far distant corporate office. No longer would a hospital be required to have a local community governing body responsible for the quality and well-being of the institution.
At the same time, payments for office visits to free-standing practices are threatened to be cut by 30 percent. More than $290 billion is needed to prevent the collapse of independent medical practices.
In response, more than 100 medical organizations, including the American Medical Association, have written a letter to the House Ways and Means Committee requesting that the savings obtained from the de-escalation of the war effort be used to offset this deficit.
The only problem with this is that defense is also taking severe budget cuts and in 2012 Medicare spending will be larger than the budget for the defense of our country (excluding funds directly related to overseas contingency operations).
Some worry these cuts may leave our country vulnerable. I am not sure if the health care industry has asked Northrop-Grumman or Raytheon about this idea. It sounds like it will start a bitter back-alley fight, scalpels against cruise missiles. Guess who will win.
Larger health care systems and mergers may not necessarily produce the desired cost savings. A 2012 Congressional Budget Office report found little savings in coordinated care projects. Little or no savings were observed in the pay-for-service models and only a 10 percent savings in a flat-rate bundle model.
Massachusetts Attorney General Martha Coakley has documented that large health care systems with market leverage provide more expensive health care.
Private equity firms are buying up charitable hospitals in Massachusetts and Detroit. It's unclear how they plan to make their windfall profits, but these guys are pretty smart and you can bet they have figured something out.
None of this bodes well for our health care system where deep and real cuts in spending are needed while the quality of health care needs to be preserved.
Health care is transforming into an oligopolistic model, one which has few market checks and balances and enormous political power. The U.S. health care bill is rapidly approaching 20 percent of gross national product.
If things do not change, health care will do to us what defense spending did to the Soviet Union.