On paper, the main parts of the ACA sound good, don't they? Exchanges to buy cheap insurance, assist the lower middle class with subsidies to buy insurance, eliminate pre-existing condition clauses etc. But the ACA was much more than that.

The main architects of the ACA were Berkowitz and Zeke Emmanual, both of whom despise fee for service healthcare. Neither even likes single payer Canadian style healthcare because that is still fee for service and lacks central control of decision making.

The ACA is a 2600 page document that refers to 50,000 pages of OTHER healthcare laws. It has many provisions that are give aways to lobbyists for pharma, hospitals and insurance companies. Here are several of the thing it does:

Under the guise of "quality" the ACA mandated physicians to get electronic medical records. Unlike every other country that uses them, the ACA did not provide them nor even set uniform standards..it forced physicians to purchase them from private vendors at great expense. It also CHANGES what these EHRs are supposed to do which forces providers to be constantly paying for upgrades. The average cost for me has been about $75,000 per year per physician in my practice (we have 4). Privacy laws prevent us from directly communicating with other physicians or even our hospital..so we must print records on paper and scan them in. If you are one entity, however, like a corporate owned multi specialty practice or hospital, you CAN share records electronically. This gives a huge advantage to hospitals to buy physician groups.

The ACA mandated that physicians enter data on "quality" measures with each visit, and the entry can not be carried over from previous visits ("cloned"). I have to reenter each patients vaccination, smoking, family history on each visit. All told, there are 180 data points I must "click" (it must be transmitted in a spread sheet fashion) on each visit before I even begin seeing the patient and addressing their problem. This takes me ten minutes out of every 20 minute visit.

The ACA limited physician ownership in ancillaries such as labs, radiology services, outpatient surgical centers, etc. Hospitals and corporations were allowed to continue building and owning these services..and charging for them.

Finally, the ACA allows hospital owned physician services to collect 30% above what private independent physicians may collect AND they also may collect a "facility fee" of $120-150 on top of that. I am limited to $93.50 a twenty minute visit..the guy my local hospital hired to compete with me gets $250 for the exact same visit. Or at least the hospital does. AND his office space is built with donated money that is a tax write off..I have to pay for mine.

There are many, many other such things. But the consequence of them has been that, preACA only 25% of doctors worked for hospitals. That number is now closer to 80%.==============================

This has ALREADY PASSED

Macra starts in 2017. It fundamentally changes how physicians are paid. Doctors will have a choice between two methods.

1) MIPS--this is fee for service but with 20% of the payment tied to "quality". They will implement a convoluted formula to assess a "quality score" based on electronic medical record usage, patient satisfaction, PQRI (entering all that data), Board Certification (it costs me close to $10,000 to maintain each of my 3 boards), value/cost ratio and "practice improvement projects. hey will tell us what data points we must collect and how in November and start collecting that data on us in 2017. This will mean we will all have to purchase new Electronic records between November and January (I shudder at the cost). They will calculate all the doctors "quality numbers" using that formula in 2019. Those who are below 50% will pay a fine which will pay a bonus to those above 50%. Initial fines/bonuses will be 4% of all Medicare billing per physician but will grow to between 9-27%. We will not get any warning where we are before the number is assigned. This means that 1/2 of the doctors who choose this method will be fined regardless of whether they hit 99% of the benchmarks if most doctors do it correctly.

2)"Alternative Payment System". Under this scenario, the doctors must still collect all the data but there are no fines. Instead, physicians are paid a capitated fee for every patient assigned to them. For my specialty, that fee is $169 per patient per month. That means that, is I see a very sick patient who requires frequent visits, I don't get paid any more than if I see a healthier one. Or if I refer my patient to Moffitt or MD Anderson, I lose my $169 dollars. So, access and referrals will drop, as will the ability of very sick people to find doctors willing to take them on.

All ancillaries will have fixed payments at the average cost (determined nationally) plus a 2% "profit" margin MINUS the 2% sequester cut.

Hospital owned clinics are exempt, of course.

Guess what will happen to private practice under this?