Well. That all sounds like issues of labor supply and demand .not the ACA
Telerad was inevitable and it's a very strong downward pressure on incomes. Not ACA related
If local groups underbid each other, that's because they have enough labor and not enough jobs. Otherwise, they have to increase their pro forma to account for higher labor costs
If physician's owned hospitals, it may makes things more profitable for the owners, but not for the rank and file.
If each hospital needs 10 radiologists, and they consolidate, then each hospital still needs 10. You could argue that if one hospital had 8 then they might have to pay more of they needed 10, but then another hospital might pay less because they have 12. Supply and demand again.
If the hospital consolidates and demands that the radiology group covers for less money, then the radiology group should say no and then it depends on supply and demand.
None of those are ACA related issues from what I can see.
ER is hurt by the ability of an ER to be run by one doc and 5 NPs. However hospitals may realize that RNs order much more testing and imaging (unnecessarily) and drive up costs.
My thinking on this is that the ACA incentivizes hospital systems to consolidate practices. They receive money from CMS to buy out physician practices in various specialties and then get to pocket the cost savings that may arise from bringing those practices in house.
This has been happening to private equity practices all over the country in recent years, as their income is still tied to reimbursement structures. The NSA was another nail in the coffin of the private equity groups but the slow trend since 2011 or so has been for hospitals to bring groups in house.
How is it that you think hospital employed positions are able to pay
more than private practice or private equity backed groups? I think it's because the government incentivizes them to bring these groups in house and call it all "integrated". The more integration that an organization has, the more government money they're entitled to.
Now, as for why private equity was able to thrive after 2011, my theory is that as documentation requirements became more onerous and outcomes were more emphasized as conditions for payment, i.e. "value based care", which is all over the ACA, it became too much to manage for previously wild-west type private practices.
For example, who has time or resources to pour over paper anesthesia records and check for 2 anti-emetics? Who has time or inclination to ask about smoking history? To document sterility in central line placement? This stuff was not very common before EMRs, and EMRs in anesthesia weren't super common in the 2000s.
So a private equity group comes in, promising the new world of "better outcomes" and "streamlined documentation." Old fogie private practice partners who can barely handle Windows 98 look at this new world and think "Do I really want to deal with this shift in my autonomous, exploitative practice? Will I still be able to string alone my new associates if I'm dealing with all this new stuff? What is a hard drive? AAGGGHHHH"
So their options become:
1. Sell to the hospital (some of them)
2. Sell to private equity (more of them, due to buyout rewards)
The eventuality of all this, though, is what you said. The reimbursements will never keep up. The NSA was very clearly a populist effort by politicians and insurance companies to accelerate this process. So now, even private equity cannot negotiate the higher rates, and the hospitals win in the end.
My theory of the ACA is that it's a multi-decade strategy to eventually consolidate all healthcare under the umbrella of organizations like United, Cigna, and Kaiser. As you've no doubt seen, the labor shortage demands that more of the
extremely large profits that these organizations get is doled out to anesthesiology services, in an effort to keep the facility fees coming.
How does this add up to being terrible for anesthesia? Mainly because it destroys the intangible satisfaction that used to come from being in a well functioning private practice, although much of those days was only due to exploitation of the new hires. However now with the destruction and rebuilding of groups constantly trust from new grads is at an all time low, and stress for people in groups that always claim “we’ve been here 25, 50, 5000 years! The hospital loves us! We’re so profitable!” Is through the roof.