I always believed that, if we could harness the entrepreneurial spirit of the American physician, we could be capable of great things. Physician decisions drive much of what is good and bad about our health care system. Their pens are the biggest driver of cost and their vigilance is the most significant driver of quality. It is a shame that physician-owned hospitals are accelerating the creation of a two-tier system by cherry-picking healthy, well-insured patients.

There are overwhelming monetary incentives for physician-owned hospitals to market to the healthiest and wealthiest, who seek a narrow list of procedural interventions. But then those physicians are rewarded with value-based payments for high satisfaction scores and low readmission rates as mandated by the Affordable Care Act.

What happens to the rest of the patients—the ones with one if not several chronic conditions and minimal if any insurance?

They find their way to teaching hospitals, which treat a disproportionate number of “dual eligibles” (seniors so poor they need both Medicare and Medicaid support), the disabled, and nonwhite patients. Teaching hospitals can quickly become underfunded and over-stretched, offering opportunities for physician-owned hospitals in the market to deliver better quality, albeit more expensive, health care to those who have the ability to choose. In spite of that, many teaching hospitals deliver excellent service and care.

In a May 14 Wall Street Journal article, Alicia Mundy wrote, “Doctor-owned hospitals are largely privately held, so it’s difficult to know their profit margins, despite the law’s growth restrictions. According to the American Hospital Directory, a private firm that provides data about some 6,000 U.S. hospitals, many physician-owned hospitals have enjoyed 20 to 35 percent profit margins in recent years.”

American community hospitals’ margins averaged 7 percent in 2010 and those of teaching hospitals are lower yet, at 5 to 6 percent. “In 2011, the first year ACA restrictions were in effect, more than half of the 30 largest doctor-owned hospitals showed operating margins that either matched or surpassed 2010 figures, and some had operating margins of more than 40 percent,” Mundy noted.

You can argue that we have had a two-tier system for a long time.

“Are you having trouble finding a doctor who will see you? If not, give it another year and a half. A doctor shortage is on its way,” writes John C. Goodman.

When demand is high, doctors tend to see those patients who have the best insurance coverage. In a study of dermatologists in 12 metropolitan areas, half of dermatologist respondents offered appointments for Botox injections with a wait time of 8 days. This is in stark comparison to previous work that showed wait times of 26 days for evaluation of a skin cancer (a changing mole) in these same communities.

A New York Times reporter interviewed practitioners and revealed, “For patients in need of services covered by Medicare, the typical wait to see a doctor was two or three weeks, and the appointments were made by answering machine. However, for Botox and other treatments not covered by Medicare (and for which patients pay the market price out of pocket), appointments to see those same doctors were often available on the same day, and they were made by live receptionists.”

Sounds like the same situations patients encounter in physician-owned and for-profit hospitals.

The tragedy is that most docs in physician-owned hospitals are delivering a level of service and quality that they could not muster in other settings. It is a testimony to the physicians, nurses, and staff at teaching hospitals that, in spite of the financial challenges facing their organizations, they respond so impressively to situations like the Boston Marathon bombings or the shooting in Arizona that injured Congresswoman Gabrielle Giffords; while purposely blind to the insurance status, color, or ethnicity of their patients.

I don’t think the architects of the Affordable Care Act envisioned their legacy to be one in which only the very affluent have prompt access to the kind of high-quality health care that historically has been available to the vast majority of Americans, while the rest endure long waits for appointments, poor quality, and rationing.

Joanne Conroy is chief health care officer, Association of American Medical Colleges.  She blogs at Wing of Zock and can be reached on Twitter @joanneconroymd.