The entire summary can be downloaded in Adobe's PDF format
Dr. Scott Gottlieb's presentation emphasized that the ACA is shifting medical risk from insurers to providers, primarily through various forms of capitation. In the future, large employers, government and insurance providers will assume risk under the ACA, but a shift in risk will transfer it to providers. To facilitate this shift in risk, Obamacare is exerting a continuing effort to get physicians to consolidate their practices into integrated delivery systems. These systems are often aligned with a hospital that serves as the central hub.
According to Gottlieb, the genesis for Obamacare may well have come from a 2009 article published in The New Yorker by Harvard surgeon Atul Gawande, that highlighted regional disparities between cost of care and health outcomes. Based on data from the Dartmouth Atlas Project, the article served as the Obama administration’s intellectual foundation guiding many parts of the ACA.
The shift in risk from insurers to providers echoes 1990 capitation models which proved largely unsuccessful. By calling for the formation of Accountable Care Organizations (ACOs), the ACA creates large groups of providers who are allotted funds to care for their specified populations. The ACA bundles payment dollars into a lump amount including outpatient and inpatient care, with an expressed goal of achieving efficiency through consolidated care. Dr. Gottlieb noted that a central ACA goal is to end the practice of fee-for-service medicine. Under this model, the physician will determine what services, procedures or drugs are utilized and the patient may never know what options were denied him because the doctor made the decision.
The shift in risk is driving consolidation and a trend away from out-patient procedures and billing. Dr. Gottlieb pointed to the trend of specialty and primary physician practices being absorbed by hospitals and a corresponding trend toward more procedures being performed in a hospital setting as opposed to an outpatient office.
The model that the ACA is based on is not new. Similar structures for consolidating care through hospital-based groups that acquired physician networks proved unsuccessful in the 1990s. Dr. Gottlieb noted that when the delivery systems of the 1990s failed, physicians were able to revert back to the former models, but that the enactment of the ACA will prohibit a return to previous patient service models.
Summarizing problems with the ACA, Dr. Gottlieb pointed to five central concerns:
Unlike the experiments of the 1990s with consolidated health care delivery models, the ACA will be very hard to unwind after the fact. The structures required to "go back" will no longer exist. The ACA takes away the very tools (i.e. underwriting) that insurers traditionally employed to manage costs, with the exception of managing the network. Under the ACA insurers will manage the networks very tightly and be extremely selective with the areas they cover and the providers with whom they collaborate to provide services. As a result, consumers will see a significant narrowing of network choice.