David Ignatius
Opinion writer March 30, 2012

Listening to the lawyers talking nonstop last week about health care gave me a headache, so I decided to consult one of the nation’s top doctors. He offered a real-world diagnosis of what’s happening in health care — and a reminder of how much it’s changing, regardless of what the Supreme Court decides about Obamacare.

My medical guru is Delos “Toby” Cosgrove, chief executive of Cleveland Clinic, a $6 billion network that’s one of the biggest and best providers in the country. Cosgrove explained how the health system is being transformed by basic economic pressures that predated the new law and will continue, regardless.

David Ignatius writes a twice-a-week foreign affairs column and contributes to the PostPartisan blog. View Archive

Talking with Cosgrove, you get the sense that the political (and now, legal) version of the health-care debate is in many ways a distraction from what matters most, which is how care is actually delivered to patients. And that’s changing, inexorably, because of underlying cost pressures.

The Supremes could throw Obamacare out the window, and we’d still have a revolution in health-care delivery that promises better treatment for Americans, at lower cost. The Patient Protection and Affordable Care Act will make this revamped system accessible to more Americans, so I’m for it on equity grounds. But even if the mandate to buy insurance disappears, hospitals and docs will keep moving into the new world of care.

We should understand that the current debate is over financing and access — not health-care delivery. As Cosgrove says, “That train has left the station.” Drawing on Cosgrove’s analysis, here’s a summary of the changes already in play:

●Hospitals are consolidating. Today, says Cosgrove, 60 percent of hospitals are part of consolidated systems; an example is Cleveland Clinic, which has locations in four states, including its headquarters in Ohio. These systems will keep merging as they drive toward greater efficiency. It’s the same process that happens in every industry, from banking to book retailing. It will make care a little more impersonal — but also cheaper and better.

This rationalization will close small and inefficient community hospitals — one U.S. official estimates that up to 1,000 hospitals should be closed. As a result, we’ll have fewer hospital beds and more outpatient and home care. What’s forcing consolidation is that reimbursements from Medicare are going to be reduced, requiring hospitals to cut costs.

●Doctors are becoming salaried, joining the trend pushed by the Cleveland and Mayo clinics and some other top providers. Today, about 60 percent of doctors nationwide are on salary, up about 10 percent from several years ago. Cosgrove predicts that this will rise to at least 70 percent over the next decade.

Salaried doctors won’t have the same economic incentives to provide expensive treatments that may not make sense for patients. They’ll be paid well (an internist at Cleveland Clinic starts at about $120,000), but they won’t receive the stratospheric salaries that once encouraged many a doc to dream of driving a Porsche.

Meanwhile, a shortage of doctors and nurses means that less senior (and less expensive) practitioners are providing more care. A physician’s assistant, increasingly, will treat minor ailments; in operating rooms, says Cosgrove, 40 percent of those present are technicians rather than doctors and nurses.

●Health records are finally going electronic, which should allow additional big savings. It’s an expensive transition (Cleveland Clinic has spent $300 million on electronic records systems over the past decade), but it will pay huge dividends in cheaper and better care.

●The federal government is gathering better data on health outcomes, which will encourage national standards for care. Hospitals already report 65 metrics for care to the Centers for Medicare and Medicaid Services. By 2014, they will be reporting 85 items that will measure everything from patient satisfaction to infection and mortality rates. Medicare payments to doctors and hospitals will partly reflect performance. Docs may complain about government intrusion, but this change should mean better care for the millions of baby boomers who will be entering Medicare over the next few years.

The health-care overhaul is happening, regardless of what the Supreme Court decides. The main consequence of the Obamacare case will be whether the justices toss out the existing rule book, forcing everyone to start over again. The justices can slow things down in this way, and they can make the system more equitable or less, but they can’t stop the revolution.

davidignatius@washpost.com