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Uncertain of Affordable Care Act’s impact, rural DOs wait and see

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This is is the second in a series of articles exploring how osteopathic family physicians in rural areas are adapting to the many changes facing health care. The first article examined the financial viability of solo private practice.

Asking rural family physicians about the Affordable Care Act’s impact triggers a range of retorts, from “I don’t have a crystal ball” to “I’m selling my practice because of Obamacare.”

Confusion prevails when it comes to understanding the 2010 health reform law. “I’m not sure how it will affect anyone’s practice because I still have no idea what’s in this 2,400-page piece of legislation,” says Craig Brady, DO, a family physician in Show Low, Ariz.

A report published three years ago by the Rural Policy Research Institute (RUPRI) projected that the Affordable Care Act will have a “significant positive impact” on rural areas. Patients, in particular, will benefit, according to RUPRI, because adults in rural areas are more likely to work for small businesses and for low wages and are, thus, disproportionately uninsured or underinsured compared to their urban counterparts.

Dr. Norris

“Our organization is currently changing its workflow and delivery of care to a patient-centered health home model.”
Dr. Norris

RUPRI estimated that the Affordable Care Act will increase the proportion of rural Americans with health insurance by 10.4% compared to an increase of 9.6% for urban Americans.

The health reform law is intended to improve access to care, but a huge influx of newly insured patients could overwhelm independent physicians in health professional shortage areas, notes AOA Trustee Boyd R. Buser, DO, who serves on the Rural Primary Care Providers Issues Group of the federal Office of Rural Health Policy. “Because a large proportion of the uninsured and underinsured are in rural underserved areas, I think this could be a big problem,” he says.

Some rural DOs, however, believe participation in the Affordable Care Act-initiated health insurance marketplace will be much lower than originally anticipated.

Family physician Brian A. Allee, DO, of Pauls Valley, Okla., for one, says that most of his uninsured patients have shown scant interest in obtaining coverage as mandated by the Affordable Care Act. “I have a fair amount of self-pay patients, and you would be surprised by how few of them ask me about this,” he says. “Usually, I will bring up the subject of health insurance with them. I’ll say, ‘You don’t have any insurance. Why don’t you go to’

“But Oklahoma is a very conservative state. Some people who are self-paying have an extreme distrust of the government, so they don’t want to participate.”

An article just published in The New York Times points out that health insurance premiums for the plans listed on tend to be higher in rural areas because of less competition. In many rural counties, only a single insurance carrier is participating in the online health insurance exchange.

In Garvin County, where Dr. Allee practices, coverage through the online exchange is available only from Blue Cross Blue Shield of Oklahoma. For years Dr. Allee has been purchasing Blue Cross health insurance for himself and his family, so he has not seen a reason to look at plans on He hopes that his current coverage will not be adversely affected.

Dr. Allee points out that working adults in Oklahoma who make less than 300% of the federal poverty level have been able to obtain affordable coverage for their families through Insure Oklahoma, a state program that is in jeopardy because of the Affordable Care Act but has been extended for another year. Funded in part by tobacco-tax dollars, Insure Oklahoma is a successful, innovative program, according to Dr. Allee. Many Oklahomans, he says, resent the federal government imposing its will on their state, which he believes has been effectively addressing access to care.

Beyond high plan premiums and disdain for federal initiatives, the technical difficulties plaguing will further reduce the number of uninsured patients who obtain coverage, Dr. Allee expects.

More significantly, the postponement of the employer mandate until 2015 has lowered estimates of the number of uninsured Americans who will become covered next year, as has the fact that half of U.S. states are opting out of expanding their Medicaid programs. Such challenges to the Affordable Care Act’s implementation are not unwelcome by many rural physicians, says Dr. Allee, who is in solo practice with a nurse practitioner and a physician assistant.

Raising fears

While they may not fully understand the impact of the Affordable Care Act, rural family physicians are convinced that it will add significantly to their administrative burden—a burden that has been increasing for many years, says Dennis James Carter, DO, who established his solo practice in Poteau, Okla., in 2002. He estimates that his practice has seen at least a 300% increase in regulatory requirements during the past decade.

Dr. Carter, who has used electronic health records from the onset, tries to proactively comply with impending rules and regulations. For example, he has been participating in Medicare’s Physician Quality Reporting System.

“I have done the first step of ‘meaningless use,’ which is what I call it,” he quips. “It doesn’t do anything for the patient, but it sure produces a lot of paperwork.”

Although paperwork headaches predate health care reform, the Affordable Care Act exacerbates them, Dr. Carter says. The law also reinforces the need to adopt EHRs, which is more difficult, time consuming and expensive for physicians converting from paper charts, he notes.

Given the expense and red tape of practicing medicine today, many older rural physicians are retiring early and many middle-aged physicians are selling their practices to become employees. Young rural physicians entering practice are much more likely to be employed from the outset than to work for themselves.

Dr. Carter notes that his patients, most of whom are geriatric, are aware of these trends. Even though their Medicare coverage isn’t affected by the Affordable Care Act, they are very worried, he says.

“My patients are running scared as to whether I’m going to remain in practice and whether the 85-bed hospital in town will stay open,” he says. “They are concerned about how the implementation of the health care law is going to affect their ability to access medical care.

“And I am not able to allay any of their fears. Just like most members of Congress at the time of its passage, I haven’t read all 2,000-plus pages of the law.”

But Dr. Carter, who does his own billing and employs a nurse practitioner to help with patient care, has no plans to sell. “I am not inclined to sell my practice at this point because my practice is successful,” he says. “We have a system in place that is allowing us to meet the needs we have to meet, and we are getting reimbursed per the law.

“I’ve learned what to do and what not to do in order to be reimbursed.”

When new regulations come his way, Dr. Carter’s approach is simple: “We just suck it up and go on and change as we need to,” he says.

But Dr. Carter’s compliance should not be construed for satisfaction. “I have a general distrust of how well the Affordable Care Act is going to work because it is not working now and the government has had 3 1/2 years to get it ready,” he says. “I don’t expect that another six months will make a significant impact on the law’s success.”

‘Good move forward’

The Affordable Care Act has many imperfections, acknowledges Raymond G. Christensen, MD, the president-elect of the National Rural Health Association.

“The law was forged in heat and argument,” Dr. Christensen explains. “A lot of its pieces are actually from the conservative Heritage Foundation, not from the Democrats.” He believes that the law and its ensuing regulations would have been better executed had Sen. Ted Kennedy not died and had Tom Daschle, Obama’s original nominee, become the secretary of the U.S. Department of Health and Human Services.

Dr. Christensen

“A lot of people who don’t like President Obama want to see the law fail.”
Dr. Christensen

“The people who could have collaborated on a better product weren’t there,” Dr. Christensen says. “So what we have is what we have.”

Nevertheless, the law’s focus on primary care does have positive effects on rural payment. Since Jan. 1, 2011, primary care physicians, both rural and urban, have been eligible for a 10% quarterly incentive payment from Medicare for primary care services.

Dr. Christensen also likes the Affordable Care Act’s emphasis on the patient-centered medical home model of care, a team approach in which a primary care physician coordinates all care with medical specialists and other health professionals, such as physical therapists and dietitians. In this model, physician extenders provide follow-up care to patients with chronic conditions. Medical homes are expected to see patients after hours and on weekends and offer same-day appointments and other conveniences.

“In a medical home, patients with complex problems receive better care than they would by seeing a primary care physician alone or by self-referring to a specialist,” says Dr. Christensen, who practices in a 15-physician clinic in Moose Lake, Minn., 45 miles from Duluth. “In its ideal form, a medical home is a one-stop shop, where patients have access to all of the health services they need.”

But while the medical home concept may be feasible in larger, less remote rural areas, Dr. Christensen says it is not as viable in frontier areas that have a severe shortage of physician extenders as well as primary care physicians.

The Affordable Care Act is far from being a panacea for the country’s health care access woes, says Dr. Christensen. But he believes the law is a step in the right direction.

“Over time, if it ever gets funded, it hopefully will be a good move forward,” he says. “But a lot of people who don’t like President Obama want to see the law fail.”

Bigger role for CHCs

Under the Affordable Care Act, federally qualified community health centers (CHCs) will play a much greater role in delivering primary care. The law calls for an $11 billion increase in funding for CHCs, which are nonprofit organizations that deliver primary care and preventive services to medically underserved populations. Community health centers have also been tasked with helping uninsured individuals enroll in health insurance plans listed on the online exchanges.

Family physician Katheryn C. Norris, DO, who works for the multisite Yakima Valley Farm Workers Clinic at its location in Grandview, Wash., says that the organization has been busy preparing for the full rollout of the Affordable Care Act by educating all of its staff on ins and outs of the law.

“We are encouraging uninsured patients to talk to our staff about their coverage needs and options,” Dr. Norris says.

In addition, her clinic has been striving to better coordinate and streamline its processes. “Our organization is currently changing its workflow and delivery of care to a patient-centered health home model,” she says. “Not only do we have medical clinics, but we also have dental clinics and various other programs, including behavioral health, nutrition and nursing outreach. We want all of these components to work harmoniously to deliver the best care to our patients.”

To encourage more family physicians to practice in underserved areas, the Affordable Care Act has initiated Teaching Health Center Graduate Medical Education grants. As a recipient of these grants, Yakima Valley Farm Workers Clinic has established a new AOA-approved family medicine residency program at its Grandview site.

Funded for two residents a year, the program is in its first year, says Dr. Norris, the program director.

“The word is getting out about our program,” she says. “Applications are up from a year ago.

“We want to recruit people from the Pacific Northwest back to the Pacific Northwest to practice. We understand that physicians tend to practice where they are from or where they are trained.”


Dr. Norris’ enthusiasm for the Affordable Care Act as a CHC physician is not shared by many rural family physicians in solo practice. Some independent physicians have deep concerns about aspects of health system reform, such as the push to move from a fee-for-service to an outcomes-based payment model.

“I like the fee-for-service system,” Dr. Allee says. “I think it works well because there is an incentive to see patients. If you’ve seen 25 patients and there are two more who really want to get worked in, you have an incentive to do so.

“We’ve already seen what systems look like when there is no financial reason to see more patients: Just look at the Veterans Health Administration and the Indian Health Service. No one is happy with those systems because the physicians have no incentive to work harder.”

Despite his misgivings about health care reform, Dr. Allee isn’t ready to change how he runs his practice. He still makes a good living, he says.

“I’m in a waiting pattern,” Dr. Allee says. “I haven’t heard enough about how the Affordable Care Act is going to work to know what the future is going to be.”