When the Supreme Court upheld President Obama’s health-care law yesterday, many interested parties had cause to celebrate. Among them were family doctors who stand to gain both influence and money from the decision.
Specialists such as cardiologists and orthopedic surgeons worry they will fall in the losers’ camp. These doctors say they face reduced reimbursements, loss of autonomy to hospitals and, ultimately, fewer patients receiving their care.
The Congressional Budget Office estimates the Affordable Care Act may cover more than 30 million uninsured people in the U.S. Keeping that care affordable means reining in medical and drug costs by reprioritizing some services. That could include reductions in Medicare payments to specialists, cutbacks that may threaten rather than strengthen prospects for quality care.
“We want more people to be insured; we want people to get the help they need,” said Peter Mandell, 68, an orthopedic surgeon in Burlingame, California.
Still, “we’ve got this sword of Damocles hanging over our heads,” Mandell said in a telephone interview. “Any more cuts and there’s really going to be a crisis in access.”
The Supreme Court upheld the constitutionality of the 2010 health-care overhaul, voting 5-4 that Congress has the power to require Americans to obtain insurance or pay a penalty. That requirement is at the center of the law, which also forces insurers to cover people with pre-existing medical conditions. The court modified the law’s extension of the Medicaid program for the poor, saying the federal government can’t threaten to withhold money from states that don’t fully comply.
Reimbursement changes and other shifts that affect how doctors practice have so strained relations within the American Medical Association that a third of its members objected to the group’s endorsement of the law. A poll by the Deloitte Center for Health Solutions in December found that 44 percent of doctors saw the law as “a good start,” while the same percentage said it was “a step in the wrong direction.”
At the top of specialists’ complaints is a much maligned formula for calculating Medicare payments, left in place under the new health law, that has ordered reimbursement cuts every year since 2002. The law also doesn’t address escalating costs for malpractice insurance to the extent specialists sought.
The law also encourages consolidation of hospitals and physician practices, accelerating a trend in the profession toward exiting independent practice and becoming salaried employees of hospitals. That poses a risk of conflicts of interest, if hospitals pressure their doctors to use drugs and devices based on cost, said U.S. Representative Charles Boustany, a Louisiana Republican who is also a heart surgeon.
It’s “basically a redistribution of how reimbursements are made,” said Boustany, who voted against the law in Congress.
“Hospitals will control health care administration and collect all the money,” said Hal Scherz, a pediatric urologist in Atlanta and president of Docs4PatientCare, an organization that has rallied against the law. “They’ll have a tremendous amount of clout. Doctors will be relegated to a perfunctory role. They’ll work for the hospital, not the patient.”
The physician divide is clearly reflected in doctor organizations around the country. The largest U.S. doctors’ lobby, the Chicago-based American Medical Association, supported the overhaul, while some of its constituencies, such as the Texas Medical Association and specialty societies including neurosurgeons and anesthesiologists, didn’t.
The one thing everyone seems to agree on is that change is needed.
“The law itself isn’t perfect,” said Kevin Pho, an internal medicine physician in Nashua, New Hampshire. “The Affordable Care Act does benefit primary care doctors, but it’s necessary because they’re undervalued in our current payment system.”
The law helps to pay for more residency slots at hospitals for medical students planning careers in primary care, and at community health clinics. It provided $1.8 billion for “medical homes,” practices in which physicians agree to monitor and coordinate their patients’ care by specialists and others.
It also created bonus payments for primary care doctors who treat Medicare patients, and raised payments for primary care doctors in Medicaid to match higher Medicare rates.
“The legislation without a doubt made a conscious effort to shift the paradigm in delivery to support a foundation of primary care,” said Shawn Martin, who works in Washington as vice president for practice advancement and advocacy for the American Academy of Family Physicians. “They did that through education, they did that through delivery reforms and they did that through some modified payment reforms.”
Glen Stream, president of the American Academy of Family Physicians, said the law pays him more for treating Medicare patients at his practice in Spokane, Washington. He said he sees fewer people declining recommended preventive tests and screenings, like mammograms and colonoscopies, because the law requires insurers to cover such procedures without co-payments.
“There’s very positive features in the bill for family medicine,” Stream said in an interview.
Elizabeth Wylie, who graduated from George Washington University’s medical school in May, said she plans to apply for residencies the law created at federally funded community health centers. Wylie, 33, taught seventh-grade English in Detroit before going to medical school and said she wants to “go back to the community where I was teaching, or a similar community, and practice primary care.”
“I really hope I’ll be better able to serve patients” because of the law, she said by phone. “More patients, as I go through my residency and enter practice, will have access to affordable coverage to seek the care that they need, particularly preventive care.”
Pho, the internist from New Hampshire, said the law’s provisions give him more time to discuss preventative health with patients.
While the Supreme Court decision ends the legal debate, the philosophical debate will remain at the center of medical care for years to come. Richard Armstrong, a general surgeon in Newberry, Michigan, said the ruling has created confusion.
“It’s going to mean a tremendous amount of complexity and uncertainty for weeks and maybe even through the fall election,” Armstrong said in a telephone interview. “Everybody’s scratching their heads.”
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