Health Reform Update - Physicians and the Affordable Care Act

May-June 2012
By: Jeff Tieman


For physicians, there are many things to like in the Affordable Care Act. The law places a new emphasis on prevention, providing coverage for services that aim to keep people healthy. It curtails the power of insurance companies to reject applicants because of pre-existing conditions or to place lifetime limits on the dollars physicians spend caring for each patient.

These provisions sound good to most physicians, who resent the power of insurance companies to deny or delay care, or to force medical decisions based on coverage policies.

The Affordable Care Act also offers incentives for doctors to work in rural and underserved areas and to stay in primary care. Once exchanges are up and running in 2014, doctors will find more of their patients with meaningful health insurance and the end of annual limits on how much care a policy allows. Already, millions of young adults are newly covered because of the provision allowing them to stay on their parents' insurance plans until age 26.

Despite greater coverage opportunities for their patients, and the law's steps to compensate for quality rather than the quantity, physicians have not embraced the Affordable Care Act, at least not en masse. Many physicians readily admit to knowing very little about the law and to struggling sometimes to explain it to patients and to one another.

Public opinion research shows that like the American public in general, physicians warm to the Affordable Care Act and its goals once they learn more of the details. According to the Herndon Alliance, a Seattle-based coalition that supports health care reform, its extensive focus-group research with caregivers shows physicians who initially oppose the law in general can be moved to support it once they have more information from a trusted source about its specifics.

Doctors are happy about preventive care opportunities, less control by insurance companies, and new opportunities to better coordinate the care delivered to patients, Herndon has found. But the docs worry about broader trends in medicine and are unsure how the Affordable Care Act will affect their practices. The biggest concerns center on autonomy, income, and whether there will be enough physicians to serve millions more people.

Even these concerns can be allayed when doctors have a chance to learn about the law, ask questions of one another and become more familiar with the actual provisions and regulations, in contrast to the heated rhetoric they've heard on the news, in the blogosphere and perhaps even from colleagues.

"Doctors ultimately care most about patients and, because of their role in the care delivery system, understand the difficulties of caring for uninsured and under-insured," said Fahad Tahir, vice president for physician enterprise at Providence Hospital in Washington, D.C., part of Ascension Health. "Therefore, doctors value the spirit and goals of ACA but their level of understanding of the intimate benefits is not there."

Tahir believes physicians are most worried about loss of autonomy, as Herndon's focus-group work confirms. Many doctors see market consolidation and health reform as possibly interfering with their ability to run their practices and plan for the future in the way they choose, according to Tahir.

Like many other hospitals and systems, Providence and Ascension are including health reform topics as part of ongoing physician education.

"A health system can't have an honest and straightforward relationship with its medical staff if we don't in turn talk about upcoming changes in an honest and practical way," Tahir said.

Bob Crittenden, MD, executive director of the Herndon Alliance, agrees with the need for education and dialogue, arguing that "you want physicians to be partners in change." For this to happen, Crittenden tells facility and system leaders, doctors should receive information on health reform from trusted sources. The source they trust the most is local and specialty medical societies — in other words, their peers.

Messages to physicians should begin where the doctors are already supportive— changes that improve system performance, rein in insurance companies, standardize billing and payment and resolve provider shortages. Doctors also need to be reassured, Crittenden said, that "we are going to solve this together" and that they will not be forced to absorb changes without having a say.

Executive leaders and physicians agree that many doctors are also disappointed the Affordable Care Act did not address the outdated and ineffective method used to calculate Medicare physician payments, known as the Sustainable Growth Rate formula, or SGR.

The SGR was instituted as part of the Balanced Budget Act of 1997, and in recent years has resulted in scheduled payment decreases to doctors. At the beginning of each year, Congress then enacts a temporary fix and promises to replace or repair the unpopular SGR.

Health reform did not include this long-term fix, so physicians who serve Medicare patients are still left wondering year to year what their rates will be and if Congress will come up with the money to prevent serious payment reductions.

Given all these factors, physicians are understandably nervous about changes they see coming as a result of the Affordable Care Act and related market factors. To help spark dialogue and get more buy-in from the physician community, Crittenden's research suggests a few areas of focus when communicating with physicians. All docs want to know how the Affordable Care Act will curtail the power of insurance companies and give them more clinical autonomy.

Specifically, when communicating with primary care physicians:

  • Provide concrete examples of things the Affordable Care Act does for physicians and patients, including its emphasis on prevention
  • Remind primary care doctors why we needed reform in the first place: Too many people were uninsured or unfairly denied coverage
  • Discuss how the law works to address the shortage of primary care physicians (10 percent Medicare bonus payment for primary care services and incentives for doctors to work in rural and underserved areas)

And with specialists:

  • Talk about how the Affordable Care Act curtails insurance company power, limits payment denials and pre-authorizations and gives autonomy back to doctors
  • Talk about how the Affordable Care Act will work to simplify payment and billing so doctors can spend more time with patients and less time arguing with insurance companies

Like many of their patients, physicians receive most information on the Affordable Care Act from the mainstream media, which does not have the best track record for delivering clear and accurate information about the law.

Also like many of their patients, physicians are more likely to embrace health reform once they become more aware of the specifics. This is not to say that every doctor in America will come to love the Affordable Care Act, but clear education and facts matter a lot to them, as they do to everyone who is skeptical of change in health care — and change in general.

JEFF TIEMAN is senior director, health reform initiatives, Catholic health Association, Washington, D.C.


Copyright © 2012 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.