In this article, author Dr. Glatter provides her perspective on what new healthcare reform might mean for EPs. “I’m really worried about what is going on with healthcare reform right now,” my electrophysiology colleague confided to me the other day in a concerned tone. “Reimbursement is dropping, our group is thinking about breaking apart to be employed by the hospital, and there are just too many electrophysiologists out there competing for patients. I’m thinking about going to law school,” he added glumly in a low tone. The healthcare landscape is rapidly shifting as the ‘Obama Plan’ attempts to rein in runaway healthcare costs, offer health insurance coverage to millions of uninsured Americans, and provide a more organized and efficient medical delivery system. Many physicians are uneasy about the changes that may occur within the next few years. The uncertainty of the entire situation, particularly for “super-specialists” like electrophysiologists (EPs), weighs heavily on the minds of many EPs. Should we consider leaving electrophysiology, like my friend is, perhaps to become a lawyer (to the dismay of many physicians)? Or should we simply ride this out as so many previous healthcare reform “fads,” which ultimately failed? In this article, I will highlight some of the major issues and proposals described for healthcare reform. I will also discuss how these changes could affect electrophsyiologists and whether these changes are beneficial or harmful to our field. My ultimate goal is to stimulate discussion, not to provide an exhaustive outline of this topic or to espouse any particular political stance.
Why Has Healthcare Reform Occurred?Without addressing any political party issues, one of the biggest reasons why healthcare reform has occurred is financial. The cost of healthcare continues to skyrocket. In 1935, health spending was 3.8% of the GDP (Gross Domestic Product) or $2.5 billion; health spending in 2003 was 15% of the GDP or $1.7 trillion, and in 2014 it is estimated to be 19% or $3.6 trillion.1 Our population continues to age, in part thanks to the explosion of new technologies and medications in fields like electrophysiology. As these patients live longer, they use more Medicare resources, which was never really anticipated to this extent when Medicare was set up in 1964 (as well as Social Security in the 1930s) as a medical “blank check.” One estimate puts the combined unfunded liability for these two programs at over $100 trillion.2
Affordable Care Act — The Changes That Have OccurredThe Affordable Care Act (ACA) went into effect on September 23, 2010.3 The most important tenet of the ACA is that it extends the life of the Medicare Trust Fund for at least 12 more years, into 2029. Because many of our patients use Medicare insurance, this is a particularly important point for electrophysiologists. The Medicare Trust Fund will be strengthened through cost-cutting moves such as reducing waste and fraud. The ACA creates a new national insurance plan if you have a pre-existing medical condition and can’t get insurance elsewhere. It also will set up a new health insurance exchange in 2014 that will make insurance affordable for more patients.3 Currently over 42 million Americans are uninsured, or about 1 in 6.4 What could these changes mean for electrophysiologists? It’s difficult to accurately predict at this point, since no one really knows how these changes will play out. It could be beneficial to EPs in that more patients will have health insurance, so more patients who currently are uninsured could utilize and benefit from our services. That may mean a bigger patient volume for ablations, defibrillators, etc. However, the unspoken fear is that our high-tech (translation = “expensive”) field could be targeted in cost-cutting moves.
Are Electrophysiologists Being Employed by Hospitals?In the early 1990s, there was a trend for hospitals to begin employing physicians directly, as opposed to doctors being employed by medical groups that served the hospital.5 This practice largely failed, mainly since hospitals were unable at that point to completely integrate individual medical groups into a large-scale hospital organization. The hospitals also overvalued many of the medical groups, which became for them financially untenable. Recently, this trend has reversed, with many more physicians now rushing to be employed again by the hospitals. Why would this be occurring? For hospitals, it makes sense to directly employ physicians. Hospitals need physicians to drive their revenue; they need doctors to bring patients in their doors and utilize their services. Directly employing the doctor means less competition with the hospital from other doctor-owned groups and allows hospitals to better align physicians with their overarching goals. A growing number of physicians are choosing to give up their current group practice and be employed by the hospital. One reason might be that older physicians may be tired of the overhead and financial headaches that come from being their own boss. A large hospital corporation may be able to provide a more comprehensive retirement or insurance benefit package, provide better human resources, offer a more efficient recordkeeping system, etc., than a smaller, doctor-run medical group. Dr. Richard Sheff of The Greeley Company found that 80% of new medical school graduates who were surveyed wanted salaried jobs to maintain a better work-life balance.5 However, this trend could create conflict between physicians at medical groups who have mainly an office-based practice versus a hospital-based practice. Radiologists, hospitalists, intensivists, ER, and general surgeons have mainly a hospital-based career, whereas internists and pediatricians are based primarily in the outpatient setting. This divergence could create a potential rift as these physicians leave their medical groups to be employed directly by a hospital. Electrophysiologists need a hospital to provide them acute care patients and as a place to perform procedures; however, EPs also maintain strong outpatient ties, particularly for patient referrals.
Accountable Care Organizations and ElectrophysiologistsThe newest buzzword is “ACOs,” or Accountable Care Organizations. This entity represents a vehicle to provide more efficient (cheaper) medical care. It is a “contracting group accountable for the quantity and cost of care in a population.”5-7 This group could be a hospital or a physician-owned practice. In ACOs, physicians can be paid through one of two ways. They can be paid under a “risk-taking model,” where the hospital or physician group takes financial responsibility for both inpatient and outpatient patient care. Physicians are paid from the profits. Alternatively, doctors could be paid under the “shared savings model,” where doctors get a fee for service and split the savings with Medicare if they reach certain patient care benchmarks. Many of these ACOs seem to be based upon the primary care model, such as encouraging internists to better manage diabetics or hypertensive patients, etc. One article described the ACO as “patient-centered medical homes.”7 It is harder to translate this model to the mainly hospital-based, technology-driven electrophysiology practices. However, should ACOs become the cornerstone of American medical care (as some advocate), it would be critical for electrophysiologists to advocate for the importance our field plays in the role of maintaining the quality of life or even longevity for many patients.
What Do Electrophysiologists Think About the Future?The Heart Rhythm Society Workforce Study Task Force recently conducted a comprehensive study to assess changes in the field of EP since the last survey was done in 2001.8 They sent the survey out to almost 2,500 physicians; almost 700 physicians responded and formed the basis for the survey. Most EPs think the demand for electrophysiology services will grow as patients age (Medicare coverage) and new patients get insurance (through healthcare reform). They feel their work volume will grow, but much uncertainty surrounds this issue. Two-thirds of those surveyed already feel they are at or are exceeding their perceived workload capacity. Roughly 81% of those asked were concerned with competition from other EPs in the area, although that did depend somewhat on which part of the country the physician was practicing in.8 Electrophysiology has typically been the fourth most recruited specialty in many medical groups.9 Additionally, concerns have been raised about having non-EPs implant defibrillators, since they do seem to have a higher rate of complications.9 Thus, there still seems to be a growing market in the US for electrophysiology services, for all of these different reasons.
SummaryHealthcare reform may bring both beneficial and negative changes to the field of electrophysiology. Although it is too soon to predict how these changes will affect EPs, staying abreast of the reforms and learning about what they mean to you is always a good idea.
1. Centers for Medicare and Medicaid Services, National Health Expenditure Data, 2010. 2. National Center for Policy Analysis, Pamela Villarreal, June 11, 2009. 3. Affordable Care Act Summary on Healthcare.Gov in 2010. 4. U.S. Census Bureau, on Govspot.com, 2010. 5. Kenneth J. Terry, MA. Medscape, August 10, 2010. 6. Health Reform Watch from Seton Hall University School of Law. Jordan T. Cohen, March 11, 2010. 7. Luft HS. Becoming accountable—Opportunities and obstacles for ACOs. N Engl J Med 2010;363:1389-1391. 8. Deering TF, Clair WK, Delaughter MC, et al. A Heart Rhythm Society Electrophysiology Workforce study: Current survey analysis of physician workforce trends. Heart Rhythm 2010;7:1346-1355. 9. Estialbo A. Is EP’s success its own problem? EP Lab Digest 2010;10:1-11.