How will the ACA impact physicians? Nobody knows, economist says
The most certain truth about the Patient Protection and Affordable Care Act’s (ACA) effect on health care is that it’s uncertain at this point, said economist Gail Wilensky, PhD, the former chairwoman of the Medicare Payment Advisory Commission, on Saturday at the AOA’s annual Advocacy for Healthy Partnerships conference in Phoenix.
“Watch out for anyone who tells you, ‘This is what your future will look like,’ because they can’t possibly know,” she said at the conference, where leaders in the osteopathic medical community met to exchange ideas about advocacy. “It’s unknowable.”
Dr. Wilensky provided an economist’s perspective on the law’s strengths and shortcomings and what they mean for physicians. A positive aspect of the uncertainty, she said, is that lawmakers have not yet spelled out many of the finer details of the ACA. For instance, it’s still unclear exactly what the federal health insurance exchange will look like, and lawmakers have not comprehensively defined the essential benefit package.
This is great news because physicians, who have an insider’s take on the health care system, will have the opportunity to help shape these details and regulations, she said.
Pros and cons
The ACA is a significant achievement in that it will expand coverage to a large swath of Americans who have never had health insurance, Dr. Wilensky said, but she doesn’t think the ACA is comprehensive health care reform.
“[The ACA] is very tepid in taking on much harder, more serious issues, which include how to slow spending and how to improve quality,” she said.
There are a few ways the ACA attempts to address quality, Dr. Wilensky said, but she doesn’t think they go far enough. For instance, while the ACA includes some value-based purchasing programs, such as higher Medicare payments for physicians who provide better care starting in 2016, Dr. Wilensky said even then, not enough of the physician’s payment will be value-based. She thinks 40-50% of physician payment needs to be value-based to yield significant changes.
What’s frustrating about the ACA, Dr. Wilensky said, is that it doesn’t address the disjointed nature of physician reimbursement.
“Two thousand pages of legislation wasn’t enough to say anything about reforming how we pay physicians,” she said. She noted that physician payments represent 20% of the health care dollar.
The current system offers physicians financial incentives to provide pricier, but not necessarily better, care to their patients. This requires them to act against their own interests to do the right thing, Dr. Wilensky said, but the ACA doesn’t address this issue.
Physician reimbursement, however, is not the sole contributor to the high costs in the U.S. health care system, Dr. Wilensky said.
“If we wanted to design a system to spend money, we would have a hard time beating what we put together,” she said. “And that’s because everywhere you look, there are reasons to expect more rather than less. We pay for more and more complex services to be provided, rather than clinicians and institutions that provide good quality outcomes.”
The litigious nature of U.S. society is another contributor to high health care costs, Dr. Wilensky said. Also, tax laws encourage people to buy more health insurance, which in turn impacts their behavior. People who have health insurance tend to use care differently, she said.
To reduce costs, lawmakers will have to make changes in many areas such as physician payment, malpractice and taxes because there’s no clear frontrunner that’s driving up health care spending, Dr. Wilensky said. But she doesn’t think the ACA addresses them all.
One idea, however, that sounds promising is the increased use of bundled payments, she said. Bundled payments encourage efficiency, which is good, but a downside is they don’t reward quality, she said.
How to thrive
The future will be challenging for physicians, Dr. Wilensky said. But she’s confident physicians can thrive in the new health care environment, and she’s hopeful they’ll see incentives start to move in the direction of providing better care. Physicians should watch for the shift in incentives, she said, and be ready to embrace them when they come. Staying flexible will be crucial, she said, as will learning to minimize costs.
“You have to figure out how to improve value and slow costs,” she said. “If you can do that, it doesn’t really matter how these other things turn out—you’ll do just fine.”
It was helpful to hear an overview of the legislation from someone who really understands what it does and doesn’t address, said conference attendee Kenneth J. Lossing, DO, who serves on the American Academy of Osteopathy’s Board of Trustees.
“What surprised me was that the ACA doesn’t really address the affordability as much as it addresses the accessibility of health care,” he said.
The presentation pulled together many of the key points that attendee Leonid Skorin Jr., DO, the president of the Minnesota Osteopathic Medical Society, learned when he was participating in the AOA’s Health Policy Fellowship, he said.
“It was very clear in regards to the pros and cons of the policy,” he said. “I liked how she was honest in her interpretation of it. Sometimes we would hear biased presentations, but I could not pick up that she had a bias in one direction or the other. She looked at it from a strictly economic perspective.”