Things are changing incredibly fast in health care -- even before the future implementation of the Affordable Care Act (ACA).  A colleague this week introduced me to a new phrase to describe a lot of what’s happening -- it’s the irresistible urge to ‘agglutinate’, he said. By this is meant that market, economic, and demographic forces are together pushing hospitals, doctors, payers, and suppliers to integrate, merge, consolidate and organize differently to survive. The huge increases in physician employment reflect this, and particularly in cardiology and CV medicine, where more than half of private practices have now shifted to employment, mostly in hospital settings. Will non-agglutinators be losers? 

There are many examples of ‘winner and loser’ dichotomies to consider in these tumultuous times. Academic hospitals, insurers and health-related venture capitalists are having banner years of profit and success, while many physicians, public hospitals and the pharma and device industries are relatively hurting. Virtually all major academic centers are full with waiting lines, and are flush with cash. When these hospital systems are hiring doctors they probably mostly are doing so to better manage care across their geographies in preparation for population-based quality and value insurance incentives -- they don’t need more patient referrals. Smaller community hospitals, however, may be more often hiring docs to capture referrals and protect their current bottom line (a strategy that will NOT work in the long run). Meanwhile, public hospitals are rightfully very worried -- they have increasing numbers of uninsured persons and bad debt, and the current political environment is very scary for their future --and for disadvantaged populations.

 Physicians employed in expanding medical groups and physician networks are increasingly in demand, are in a good position. Systems that are not preparing for more emphasis on population-based global budgets are going to be very disadvantaged at some point, I believe. 

Insurers are also doing very well right now as well (check Wall Street performances). Why? In tough economic times, people are avoiding care, probably to save on higher co-payments. Per capita visits to doctors and to pharmacies to pick up medicines are way down in the past three years (pharmacies are worried about these trends, which also will increase unnecessary admissions for chronic diseases). Big labs like Quest Diagnostics also note a decline in business related to people not willing to spend money on their co-pays or doctor visits. These trends raise profits for payers. And, as in Kaiser Permanente’s recent experience, significant reductions in office visits result from new Internet patient-physician connections that allow people to be treated virtually -- at major cost savings and increased convenience.  

Meanwhile, the pharma and device industries are shifting their workforces and focusing offshore to expanding markets and away from what they experience as a semi-hostile regulatory environment and focus on price controls here.  

The thing about all of the above is -- it’s all subject to change. Today’s winner could be tomorrow’s losers, and vice versa.  We’re managing through uncertainty. It’s stressful, and largely based on what happens to spending and access to care in the political environment. And a lot will be determined based on the circus-like debt ceiling negotiations. Ouch.