It’s a common mantra, but it bears repeating: correlation does not equal causation. Or, in layman’s terms, the fact that two things happen at the same time doesn’t mean that they’re related to each other. There needs to be a stronger link than that.

Unfortunately, Scott Gottlieb seems to have forgotten this in his recent Wall Street Journal column where he claims that PPACA will lead to more consolidation of physician practices and, thus, to less consumer choice when it comes to providers.

Consolidated practices and salaried doctors will leave fewer options for patients and longer waiting times for routine appointments. Like the insurers, physicians are responding to the economic burdens of the president’s plan in one of the few ways they’re permitted to.¹

Let’s think about this for a second. While consolidated practices and salaried doctors do mean a decrease in choice, is PPACA really the cause?

A white paper from Yale University produces a startling statistic along with some dates:

Overall, 24 percent of physicians were employees in 1985, but by 1994 this figure had risen to 43 percent.²

The last time I looked at the calendar, 1994 was sixteen years ago. Health insurance as a major issue was barely on the radar then; even the concept of managed care was somewhat new. Still, some have blamed managed care for the reduction in physician availability, even though that was proven false.³ Others have blamed HIPAA.

It seems that every time there has been a major change in the health coverage environment, someone has claimed that it would mean the end of the independent physician and consumer choice. I have another theory.

Could it be that the trend away from physicians as independent business owners to physicians as salaried employees is caused not by changes in the health coverage environment, but rather changes in the small business environment?

• Health coverage for small business employees has become prohibitively expensive, and it’s even worse for sole proprietors. Larger companies, with their more attractive employer-sponsored plans, carry a much better benefit.
• The cost of medical malpractice insurance has soared sky-high, but a large company can purchase a group plan that, while initially having larger coverage, amortizes out to a lower cost-per-physician.
• Salaried workers have a much more predictable monthly income, which makes budgeting easier. Given the current banking and finance environment — and the average student loan balance of a medical school graduate — a steady salary is rather more attractive than the cyclical nature of small business income.

It’s a lousy time to be a small business owner in this country, particularly in a field that requires high insurance premiums both for the employer-sponsored plan and for the business’ own liability. Despite all the jokes, physicians aren’t stupid. They can recognize that, and recognize that working independently might not be in their best interests.

That’s not caused by PPACA. That’s caused by the economy.

1. No, You Can’t Keep Your Health Plan (Scott Gottlieb, Wall Street Journal)
2. The Rise of Managed Care and the Decline of Physician Self-Employment (Andrew Pearlman, Yale University Seminar) PDF File
3. Is Managed Care Leading to Consolidation in Health-care Markets? (Gregory Vistnes, Health Research and Education Trust