health care for profit is sickWelcome to the corporatization of health care.

As we move forward with implementing the Affordable Care Act, providers of health care are having to adapt to new requirements intended to provide for more accountability and more efficient use of resources.

Some new requirements end up functioning as a disincentives to participating in Medicare as health care providers. Because of the details of how some of these reforms are being implemented, what I predict — and, what I fear — will be a result of the Affordable Care Act will be a widening of the gap between the “haves” and the “have nots” in what health care people can get. If you have the money to pay for everything you need , you’ll have access to the health care you need. If not, then you’ll only have access to the health care your insurance, if you have any, will allow you to have. That’s the difference between patient-centered care and insurance-driven care.

Change is often difficult. One example is a recent change in CPT codes for psychotherapy. CPT codes are the codes used when a health care provider of any kind bills a health insurance company for what they have provided a patient that relates to a diagnosis the patient has. In order to be paid through insurance, there has to be a diagnostic code and a CPT code that corresponds with the diagnosis. For psychotherapy, CPT codes communicate the length and type of service that was provided. While both psychotherapists and insurance companies have been adjusting to using the new psychotherapy CPT codes, insurance companies have been denying claims. Meanwhile, therapists’ business expenses — office space, licensing fees, malpractice insurance, telephone, etc. — didn’t stop simply because the American Medical Association issued new CPT codes that insurance companies and providers were not yet accustomed to using. The impact of this change has been experienced by the psychotherapist and their patients/clients — or, to use the insurance companies’ term, the consumers.

As a patient who “consumes” health care, as a mental health professional who provides health care and as a citizen who strives to be informed on the issues before I vote, I believe it is important for us all to be aware of and understand the impact that even these seemingly small details can have on our access to quality, affordable health care. Truth be told, patients and therapists alike miss the time we had together when we were using the previous CPT codes. The “50 minute hour” is now 45 minutes long. In more corporate settings, appointments may be only 30 minutes long. How can patients and therapists do sensitive, deep work in such a short period of time?

Experienced and well-established physicians, psychotherapists and other health care providers are likely to experience some of the new requirements of the Affordable Care Act as incentives to opt out of being Medicare and health insurance “in-network” providers. Historically, what happens with Medicare — reimbursement rate changes, increased paperwork and other administrative requirements that providers and/or their staff have to do in order to get reimbursed for the care that’s been provided –usually leads to the same happening with private health insurance. For years, we who have been providing health care have experienced the demands from health insurance companies on us to have increased, while reimbursement rates for our services have either remained the same or decreased. As a result, our net incomes have declined.

In short, it has increasingly become difficult for health care professionals to make a living. At the same time, health insurance companies — even non-profit companies — have continued to make handsome profits. The bottom line is that it is important for every health care professional and every “consumer” — all patients — to know what’s happening to the money we spend for health insurance premiums and to what’s happening with Medicare, to which anyone who has ever earned income has contributed to through their payroll or self-employment tax contributions.

At the same time, psychotherapists and other health care providers have experienced a significant challenge and, for many, an unacceptable loss of clinical and professional autonomy. Your primary care physician would most likely prefer to spend more than a rushed 15 minutes with you. But, if you’re paying for that care using your health insurance, then she or he most likely cannot afford to spend more time with you. The CPT code for your standard appointment with your primary care physician provides for 15 minutes. Your psychotherapist probably used to provide a 50-60 minute psychotherapy session. Now, because the CPT codes for psychotherapy have changed, effective January 1, 2013, most appointments for individual psychotherapy will last only 45 minutes.

To stay in business, health care providers of all sorts are having to leave solo or small group practices to form or join large groups. Often, those large groups are corporations that employ health care providers. People who wish to or, more likely, have no other choice but to rely on their Medicare benefits andor private health insurance to pay for their health care will continue to lose access to the independent, autonomous providers of their choosing. Instead, their Medicare or health insurance will direct them to receive care from providers employed by corporately-owned group practices or clinics. The health care professionals they employ will be required to achieve productivity standards that their employer has determined necessary to succeed financially. Also, these health care providers will be required to use metrics-driven, “evidence-based” practices in the care decisions they make and the care they offer, regardless of whether or not that is what they would independently deem to be best for their patient. Why? Because that is only what Medicare and private insurance companies will reimburse. Their jobs will be to provide services based on what Medicare and private health insurances will pay for — payer-driven care — rather than what patients need, or patient-centered care.

Already, we see the great divide happening and deepening. Some physicians, psychotherapists and other health care providers are opting out of participating in Medicare and health insurance panels. Their patients pay cash up front when they see them. If they have insurance, their patients can submit claims to try to be reimbursed, if their insurance will cover the services provided and if it provides them with the option to see an “out of network” provider. Now, even with an “out of network” option, some insurances are requiring clinicians to provide treatment plans and other documentation before they will reimburse the patient. Eventually, we’re likely to see the “out of network” option disappear. People who can afford to will simply pay cash.

For the last 10 years or more, we also have been seeing a trend towards “concierge” care. Patients pay an annual fee to their physician to retain them. In return, they receive greater access to and a higher level of care from their physician. Concierge care is the higher end of the corporatization of health care. Otherwise, if the attention you need is not on your insurance plan’s menu, you’d better be able to pay cash or make do without. If the medication you need is no longer on the formulary for your insurance plan, then you either better have the money to pay for it out of pocket or be able to get by without it. If the health care you need doesn’t fit the metrics-driven algorithms, decision trees and research — as well as the politics — that decide that what you need is “evidence-based” care or not, then you’ll likely have to pay for it on your own or receive considerably less help to pay for it from your health insurance.

Although I certainly understand and agree that we need to reduce health care costs — it’s true that growing health care costs are a significant problem contributing to our nation’s economic woes — I hate to see  our health care system increasingly mirror the growing inequity of wealth in our country. I had hoped that health care reform would not only provide for increased access to health care for all but also provide for more patient-centered care rather than expanding payer-driven care. Having more people covered by health insurance does not equate to giving more people access to the health care they need.

“Evidenced-based” practices may be based on the science of health care. However, the validity and reliability of the data and how its interpreted may, in some instances, be questionable. And, politics — in some cases, literally, lobbyists — influence what’s decided to be “evidence-based” from what’s not. Even if “evidence-based” practices always provided the best possible care, mandating it by refusing to pay for anything else starves the art of what health care practitioners do. It requires care decisions based on macro data that may reflect what’s true for public health but not be accurate, relevant or helpful to the individual patient who is sitting in our office looking to us to help him or her feel better, function better and become healthier.

Much like teachers who must teach to the test so that their students will perform well on high stakes standardized tests rather than learn to acquire critical thinking skills needed to succeed in life, health care professionals have been contending with increasing challenges to their professional autonomy. If we’re “in network,” to get paid, we must follow the guidelines required by payers (i.e., Medicare, private health insurance) rather than respond to what our patients need. When payer requirements and patient needs don’t conflict, everybody wins. But, when those requirements are not in sync with what patients need and what our clinical judgment tells us, then we have to choose between opting out of the payment system that makes the care we provide accessible to more people or surrender our clinical, professional autonomy and provide whatever we can that’s on the corporate health care menu. And, if we stay in the system as in-network providers, we have to spend a lot of time and money to pay for the equipment, software, staff and other administrative costs of doing business with Medicare and health insurance companies.

And, at least for the initial roll out of the new psychotherapy CPT codes, we will have to resubmit claims and do without getting paid for the services we provided to allow the insurance companies time to adjust to using the new CPT codes. Meanwhile, as health care professionals and, at times, as patients, we’re all thinking there must be a better way.