The Impact of the ACA on Primary Care Part One: what we know now.

In the next several blogs I will explore how the ACA has impacted primary care as of 2015. In my book and my previous blogs I have talked about how quality indicators and electronic medical records, in their current forms, can detract from the ability of primary care physicians to provide optimal health care to their patients, can disrupt the doctor-patient relationship to the detriment of both doctor and patient, can squander physician time with meaningless tasks that do not improve clinical outcome or patient satisfaction, and have increased physician burnout while driving many doctors out of primary care. I also discussed some of ACA's value initiatives, such as the medical home model, and how they are not achieving their goals, even though they will be a large part of primary care staring in 2016. As I state in my book, both doctors and their patients are becoming frustrated with a system that devalues the doctor-patient relationship and elevates the importance of metrics and technology above a more personal touch to achieve health goals. The question is, in what ways has the ACA impacted what transpires between doctor and patient in the exam room?

I recently discovered an article written in 2013 by Alyene Senger of the Heritage Foundation. Heritage is a conservative think thank that has been (often very unjustly, in my opinion) deriding the ACA for partisan reasons with little truth to what they claim. In fact, much of the ACA has been successful, including increasing the number of people now able to receive insurance, and preventing insurance companies from denying coverage to people with preexisting illness. But the politicized debate over the ACA is not very constructive. Within that debate lies an equally significant debate that has been largely ignored by the press but which will have tremendous impact on every doctor and patient, as well as on the shape of health care delivery in the future. It is that debate, which is completely non-partisan, that we will address in the next few blogs. The Heritage article is a good starting point for discussion. Although the article does decry Obamacare in a partisan venue, its concerns that focus on the doctor-patient relationship are very reasonable and their evaluation will help us to see in which direction health care reform is moving under the ACA’s auspices and what, if anything, should be done to alter that direction.

“Obama’s Impact on Doctors—An Update” from August 2013 begins with a declaration: “Specifically, physicians will be subject to more government regulation and oversight, and will be increasingly dependent on unreliable government reimbursement for medical services. Doctors, already under tremendous pressure, will only see their jobs become more difficult.”

Currently, doctors of all political stripes are apprehensive to outright hostile about how the ACA has impacted their practices. As mentioned in a previous blog, doctor burnout has accentuated under the ACA, with 50% of doctors stating they are burned out, many of whom are in primary care, and many of whom point to aspects of the ACA (such as EMR meaningful use) and the ACA itself as the reason for burnout. Similarly, most doctors decry the explosion of oversight and regulatory pressure that has hit them via ACA rules, and 85% of doctors feel that they have no control over their practices. Thus, we have to take the Heritage statement seriously; doctors are not very happy with the direction of health care provision under ACA guidance. Similarly, as we will discuss, patients are not happy either, and their frustration with the evolving system may only get worse. Although we typically only hear about aspects of the ACA dealing with who is insured and how (with republicans and democrats feuding incessantly about the same narrow issues), it is really the debate about the ACA’s impact on the doctor’s exam room that may have even more profound repercussions.

The Heritage article lists three areas of concern in the law. One has to do with the Medicare Innovation Center, which uses its $10 billion to assess the effectiveness of new modes of health care, including accountable care organizations (ACO’s), medical homes, strategies to reduce hospital re-admissions, ect. States the article: “Much will depend on how exactly the findings and recommendations will be implemented or applied, and which financial incentives, penalties, or regulatory requirements will accompany them. While findings could very well prove valuable to physician and patient decision making, there is also a danger that recommendations or guidelines could interfere with the doctor-patient relationship or retard clinical innovation in the delivery of care.” A second concern is related to the first, and targets the ACA’s pay for performance programs, many of which derive from the innovation grants; these will have a huge effect on physician salary and behavior starting next year. The catch word for these programs is population health: a model of care that makes physicians responsible for the health of a specified population, with financial incentives and disincentives put in place based on how much that population costs Medicare. The ACA has labeled this as paying doctors for value (performance), and a large chunk of primary care physician payment will be tied to certain value parameters that CMS will institute in 2016, as we have talked about. A third area of concern in the article is the Independent Payment Advisory Board (IPAB), a non-elected board of non-physicians who will be determining how physicians should be paid. That board, as both my book and the Heritage article describe, is opposed by many in the medical field, including noted liberal doctors such as Howard Dean.

The Heritage article concludes: “While these programs are designed to improve the quality of care, the danger is that they will create powerful economic incentives to comply with standardized guidelines at the expense of individual patient care, encouraging doctors and other medical professionals to ‘check the box’ and achieve a high and financially beneficial score as a condition of participating in the government’s health programs.” This is a very serious concern that I address in my book and that we will talk about in the subsequent blogs. Stated simply, do all of the value and quality programs instituted by the ACA actually enhance quality and value or do they do just the opposite by standardizing medical care and disrupting the doctor-patient bond? Do they impact how doctors and patients interact, and is that impact a boon or barrier to quality cost-effective care? As we are checking boxes and following ACA protocols, are we helping our patinets stay healthier, and are we and our patients more or less satisfied by these changes?

If we are going to accurately assess the impact of the ACA on health care delivery, we must stop all the partisan bickering; we must carefully look at how the law has impacted the doctor-patient relationship, rather than simply rehashing the same debate about larger insurance issues that do not affect the vast majority of patients; we must see how the law has altered the ability of primary care doctors to take care of their patients, and at what price; and we must honestly measure if the novel programs being imposed on doctors are going to reform health care in a positive way, or are going to impair real reform. What happens in the exam room, between doctor and patient, represents the meat of medical care, and no one in the press has adequately looked into the ACA’s role in altering that vital landscape.

In future blogs we will talk more about the medical home model and the new chronic care note that the ACA has developed to help promote physician value; we will talk about why so many doctors are leaving primary care and why so many others are abandoning private practice and flocking to hospitals, and what that may mean for patient care; and we will summarize the impact that quality and value measures are having on primary care practices. Ultimately, unless practicing primary care doctors advocate for themselves in the political arena, then much of what we discuss will be imposed on them without any of their crucial input. Only by understanding the issues at the most basic level can we know what is working and what is not.