Healthcare déjà vu

The 2011 Thomson Reuters/HCPlexus National Physicians Survey was conducted during another time of transition in healthcare delivery – probing physicians for their opinions on how the outcomes of healthcare reform will affect their patients, their practices, their profession, and their compensation. The survey of 2,965 physicians, which included primary care doctors and specialists from every state in the US (and the District of Columbia), was conducted via fax in September 2010 and followed-up with phone-based interviews in December 2010 and January 2011. The results convey a negative sentiment among physicians regarding the present health care reform efforts. Sixty-five percent believe that the quality of health care in the country will deteriorate and 58 percent believe the impact on patients will be negative. 

The most striking result of this survey, however, was the lack of understanding of Accountable Care Organizations (ACO), a foundational component of healthcare reform. As the reform legislation states, by January 2012, the Centers for Medicare and Medicaid Services will start recognizing this new form of healthcare collective by providing fiscal incentives for groups of providers that provide good quality care to beneficiaries while keeping down cost.

Essentially, the ACOs make providers jointly accountable for the health of their patients, giving them strong incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work they’d have to seamlessly share information. Those that save money while also meeting quality targets would keep a portion of those savings. 

On paper it is hard to argue with the spirit of the ACO. Our own research conducted in 2009, found that inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.

Further, the Congressional Budget Office estimates that ACOs could save Medicare at least $4.9 billion through 2019. 

Despite the noble intentions of the program and its seemingly positive end-result, our survey of practicing physicians indicated that only 12 percent were in active discussions to participate in an ACO and that 45 percent did not know the term at all. This is eerily similar to the early days of HMO’s when few doctors knew what a Health Maintenance Organization was either. 

Digging deeper into our survey data, we found that the smaller the practice setting and more procedurally based the practitioner, the more negative the response. Health care reform is promoting greater coordination of care and bundled payments, so it is easy to understand why solo practitioners and those who receive the majority of their compensation through procedural reimbursement would be the most concerned about the imminent changes. They are also the ones who have frequent one-on-one contact with their patients – providing the potential for another grassroots campaign.

So why are they wary of health care reform? The physician responders believe that there will be an increased use of mid-level practitioners to meet the increased demands on primary care and that compensation would be less fair in the future. Primary care providers expressed concern that hospital and specialty-run care systems would not recognize their value. Specialists see their income and autonomy waning as health systems organize and payments become bundled or more comprehensive around episodes of care. 

The primarily negative reaction to health care reform signals a troubled physician population – be it primary care physicians or specialists – with many expressing strong feelings that either they or their colleagues may soon be disenfranchised. That’s a big problem for the reform agenda.

Coordination of care through ACOs is central to the incentive structures built into the reform legislation because it is thought to be one of the best ways to curb waste and increase efficiency – especially in the face of another 30 million insured patients being added to the system. But coordination only works when all of the players agree to work together and start building the infrastructure and working relationships needed to do so. If, at this late stage in the game, nearly half of physicians do not even know what an ACO is and only 12 percent are starting to participate, the initiative will not produce measurable benefits to the healthcare system. Worse yet, with many physicians actively voicing concern that the bundled payments associated with ACOs will marginalize their value, we are beginning to see the stage set for a physician-led campaign against a major tenet of the present reform movement. 

Based on current physician sentiment, the government may have created a participation-based incentive structure that will have few participants. At this pace, if the current healthcare reform legislation survives its most recent judicial and legislative challenges, it will surely face more concerning battles in the clinical setting. To keep history from repeating itself at great cost to the American taxpayer and even greater political cost to the administration, steps need to be taken quickly to educate and engage frontline physicians and other providers on the value of ACOs, as well as lobby for their support of the initiative. The alternative is a practical insurrection that will dash any hopes for efficiencies of scale from coordinated care as costs skyrocket in response to the huge influx of the newly insured. Policymakers and administrators must start to include doctors in the discussion. This has become more than a partisan issue – it is a human issue. Health care reform, whatever the version, will find it difficult to aid the consumer without the buy-in from physicians. 

The time we all have with our doctors is precious and should be focused on health. Let’s not spend it listening to their critique of health care reform as an outsider again.

Raymond Fabius, MD, is Chief Medical Officer at Thomson Reuters. In addition to being a pediatrician, Dr. Fabius has held health and wellness corporate leadership roles at Walgreens, I-trax, General Electric, and Aetna.