As health care has evolved, becoming ever more complex and sophisticated, it has also become more costly, Dr. Cirillo said. “New technologies are costly; new procedures are costly. Then Wall Street woke up to the fact that there’s a lot of money floating around the health care business and decided to get involved.”

Insurance companies consolidated first, then hospitals became health systems, he said. “Last in this triangle is us, the emergency physicians. Now we’re struggling with the need for size in order to be financially successful, which means losing individual control over our working conditions,” Dr. Cirillo said. “I think the discordance that many physicians feel is that if they are part of a big group, they’ve lost their sense of who they are.”

“They don’t feel they have a voice in their working conditions, and that is particularly challenging for emergency physicians because of where they practice,” Dr. Cirillo added.

Dr. Crane suggested that the “horizontal” integration of insurers coming together across large geographic areas and populations is not the only relevant issue affecting emergency physicians. “What is even more concerning is vertical integration — health plans buying and owning physician groups. This has been clearly demonstrated in recent investigations of Optum, wholly owned by UnitedHealthcare, the single largest physician group in the U.S., with over 100,000 clinicians.”

Optum has been accused of upcoding charts and providing false diagnoses in support of higher Medicare Advantage managed care rates,⁶ Dr. Crane noted. “More recently, these investigations have been expanded to include how it reimburses the doctors it owns for the services they provide. These insider reimbursement practices threaten the very viability of practices large and small and tip the scales in favor of payers. We should be very concerned when insurers have control over both the re-imbursement and the medical care decisions of physicians.”

Mr. Beresford is an Oakland, California-based freelance medical journalist. 

References  

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