Editorial

Preparing for the Impact of Health Care Reform Failure of past governmental health care initiatives to solve access to care and cost problems makes skeptics wonder whether the bluster of election year rhetoric will really lead to meaningful and effective changes in the health care system. I With a flurry of initiatives to reform physician payment, establish relative value scales, and create preferred providers through cut-rate high-volume surgical practices, the government may be causing physicians to take their collective eye off the ball when trying to decide where to place their efforts in planning for the future. While these government programs threaten the fabric of traditional medical practice, they are not likely to be the models for future changes in the health care system. Instead, through a squeeze on employers to provide health care coverage for all workers, the government will cause the private sector to take the de facto lead in solving many of the inequities of the present system. Commercial insurance companies are already feeling the brunt of new legislation in New York State that forces them to cover all who apply for health care coverage irrespective of their health status. Many other states are considering laws to force employers, insurers, and providers to guarantee uniform access to high-value care-"value" equalling the product of quality divided by cost. A number of cities have already seen a major emphasis on contracted care via a variety of negotiated arrangements, none of which involve the government. The essence of many of these plans is to control costs by limiting the freedom of patients to choose providers, thereby predetermining costs through prospective agreements. When (if does not seem to reflect reality anymore) these plans reach your area, the winners will be those who control patient flow. Group practices that can provide the gamut of services will likely have an advantage over solo practices in negotiating total care packages. But the ability to control entry level care will allow the practice to control the secondary and tertiary care. Thus, most experts are advising providers to concentrate on entry level (primary) care in preparing for the future. With this in mind, residency training programs will do well to strongly consider a renewed interest in primary care rather than subspecialty practice. While subspecialty fellowships may add to the background of newly trained ophthalmologists, formally accrediting fellowship training programs may serve to detract from the breadth of practice that will likely be beneficial in a managed care environment. Despite the consternation of some physicians with regard to the Resource Based Relative Value Scale, the Physician Payment Reform Commission, and Preferred Provider Organizations, most agree that it is short-sighted to concentrate only on these particular government initiatives when the private sector may have at least as much to say as the government about the future of health care reform in this country. Thus far, the government has shown little or no ability to provide meaningful and coordinated guidance to the health care system. In fact, its efforts have resulted in an environment that catalyzes unbridled expenditures rather than tempering them. Perhaps now, the government can muster the political will to deal effectively with the access and cost issues that are raising the hackles of the public. But if the past is prologue, there is at least as much chance that the government will continue to churn out plans from one hand that counteract plans from the other.

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Ophthalmology

Volume 99, Number 8, August 1992

Rather than be confused by the government's actions, physicians should realize that the government is consistent in its inconsistency. Rather than assume that these inconsistencies will lead to naught in terms of health care reform, physicians should assume that change is upon us and begin to prepare for it. The private sector, driven by legislation, will likely playa major role in changing the system. This may mean consolidation of medical practices. It certainly will bring about the need for physicians to learn about terms like market share and controlled access. Many players who have been watching from the sidelines are starting to enter the game. The competition will be keen, and there will be winners and losers. The winners will be those who kept their eye on the ball. Reference 1. Lichter PRo Federal health care hoops and confused providers. Ophthalmology 1992;99:1011-12.

Paul R. Lichter, MD Editor-in-Chief

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Preparing for the impact of health care reform.

Editorial Preparing for the Impact of Health Care Reform Failure of past governmental health care initiatives to solve access to care and cost proble...
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