Physicians opposed to healthcare reform may feel like they're caught in a "Back to The Future" scenario. All that hope and hype over lawsuits against healthcare reform for the past two years has gotten physicians squarely back to 2010, when it all started. With the U.S. Supreme Court generally reaffirming the Patient Protection and Affordable Care Act, docs are trying to decipher their own diagnosis for what's ahead.
Many physicians who deride healthcare reform call it "Obamacare," just as disapproving non-healthcare professionals do. Should they now call it "Supreme Court care," too? In its 195-page decision, the court mentioned the word "physicians" only twice and "doctors" not at all.
In case you somehow missed it, the court was sharply divided, voting 5-4 to uphold the key provisions of the PPACA, including the controversial individual mandate that requires people to either purchase health insurance or pay a penalty. Chief Justice John Roberts was the deciding vote. The court also left it up to the states to expand Medicaid coverage.
Indeed, as the court was divided, so, it appears, is the population of physicians, much as they were before. Some say the court did the right thing, and the PPACA will properly bring millions more uninsured people into healthcare. Others contend it was a bungled effort at overregulation. Both sides seem to be uncertain over what the Medicaid ruling may bring. "It was the right thing to do," says one doc. "It was the worst decision ever," says another.
Amid the vehemence and vitriol, physicians appear to be diverging along two paths: embracing the court decision with some enthusiasm, or stepping up their political activism in hopes that the presidential election may make a difference. "Now is the time to take back medicine!" the Association of American Physicians and Surgeons roars on its website. "The Supreme Court has ruled and the fight has begun anew. Will it be easy? No. Does it have to be done? Yes."
Along the way, for moderates, liberals, cardiologists, and oncologists, there are loads of uncertainties with reimbursement and regulatory challenges, as well as key issues that the Supreme Court never touched on, such as tort reform and the Sustainable Growth Rate formula, which governs the growth of Medicare physician payments annually.
Building a consensus among physicians may be difficult. It's taken years for healthcare leaders to smooth rough edges and improve day-to-day care in hospitals, where physicians are far more comfortable than in the political arena.
Glen Stream, MD, MBI, president of the American Academy of Family Physicians, acknowledged to HealthLeaders Media that bridging the gap between physicians with opposing feelingscould be difficult, even within his own organization. "It's a challenge," he says, noting that some of his members are angry over the high court's action as well as the academy's support of the law. "My hope is that the angst of today passes, and we can work together tomorrow to find common ground," Stream says. He adds, "I was pleased to see it upheld. It's not perfect, but we can go forward with the structure it has."
Kim Bullock, MD, an emergency department physician who works in Washington, D.C., hospitals in both high- and low-income areas, says she's concerned about what will happen to various factions after the high court decision.
"Now there is either bridge-building by the different factions, or continued polarization," she says. "Bridges must be made within the profession, just as among the populace. The landmark legislation has generated strong opinions, and I do believe that was part of the intent by the authors. Finding consensus will make it easier for physicians to negotiate the changes in the details associated with the law."
The American Medical Association, which supported healthcare reform, also endorsed the Supreme Court decision. They especially favored the individual mandate provision, which will open the door for millions to obtain insurance coverage.
But many physicians don't believe doctors will be in a financial position to handle more patients, noting current shortages of primary care physicians and regular overflows in emergency departments. Moreover, many doctors don't believe the law can attain its insurance coverage goal. A survey of primary care physicians conducted by MDLinx immediately after the high court's decision found that 64% said they didn't think it would achieve the law's objective of 100% coverage of all Americans.
Adding an estimated 19 million people into Medicaid by 2014 also may strain payments to physicians, which currently come in at only slightly more than half of what private insurance pays, according to the conservative Heritage Foundation. The lower payments already discourage doctors from accepting Medicaid payments, says G. Keith Smith, MD, an anesthesiologist in Oklahoma City, OK, who opposes the Supreme Court decision. "It is a disaster for physicians," Smithsays. "It's incredible how much more difficult it will be [for physicians] to see Medicare patients. Many will opt out. We're all scratching our heads and not making any headway. This is so dysfunctional."
In addition, Smith says, many physicians oppose the Independent Payment Advisory Board to contain cost growth in Medicare. As IPAB cuts reimbursements, seniors will experience growing access problems. Congressional committees continue to examine the IPAB.
In the meantime, the Supreme Court's decision to leave Medicaid coverage up to the states clearly will impact physicians and their workload. Before the court's decision, hospitals and providers were expecting millions of low-income and disabled patients to join Medicaid's ranks. Now, Republicans are ramping up efforts to thwart state involvement in Medicaid.
"I think physicians generally want to provide quality healthcare and I think there are going to be barriers," says Michael Fleming, MD, FAAFP, chief medical officer for Amedysis, a provider of home and healthcare based in Baton Rouge, La. Fleming described himself as generally neutral about the Supreme Court decision.
For physicians, it's the uncertainty that confuses, frightens, and annoys, he adds.
"Physicians are among the most change-averse humans on the planet," adds Fleming says. "Docs have been burned [in reimbursement issues] and primary care docs have been burned more than most. Cardiologists have been burned, their fees have been slashed. Radiologists have had their fees cut. So basically you are asking physicians, ‘You want to accept something that doesn't have details yet?' How am I supposed to feel about that? That's where the negativity comes in."
But the PPACA decision also has immediate positive impacts in other areas, according to the AMA. It can begin to alleviate administrative burdens on physicians, such as streamlining insurance claims. In addition, the decision ensures that the act carries out important improvements in healthcare, AMA President Jeremy A. Lazarus, MD, said in a statement. Included in that assurance is putting an end to coverage denials for pre-existing conditions, and allowing 2.5 million young people up to age 26 to stay on their parents' health insurance policies.
Regardless of the Supreme Court decision, many physicians are on board for movement from fee-for-service to value-based care, as well as exploring payment options ranging from bundling to those included in accountable care organizations, with an emphasis on patient-centered care. "The devil will be in the details how it all works out," Fleming says.
As part of the crowd that amassed last week outside the Supreme Court, I was told the decision drew some of the loudest and most vociferous crowds in memory outside its marble walls, with many people carrying placards praising the decision or denouncing it, some with megaphones, some with drums, arguing or chanting for whatever position they held.
One physician who stuck out in the crowd was Michael Newman, MD, a Washington D.C.–based internist. He wore a white coat and carried blue binder notebooks. He wasn't part of a group of protesters, but simply a practitioner who works a few blocks away from the Supreme Court building and wanted to see history unfold. He identified himself as a supporter of healthcare reform. Newman acknowledges he may be in the minority of physicians who favor what the Supreme Court has done, but is pleased that it may result in more care for the currently uninsured, for instance.
"There is definitely disagreement about the law, but it's not up to the Supreme Court to fix the problems of healthcare. It's up to the people,." Newman says. "The Affordable Care Act is not the greatest piece of legislation, but the best piece that could be enacted."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
