DOs divided over reform legislation

With emotions ranging from relief to fury, osteopathic physicians have been voicing their views on the landmark health care legislation President Barack Obama signed into law in late March. The legislation, which will increase the ranks of the insured by more than 30 million by most estimates, contains many health insurance reforms but, to the chagrin of many medical associations and physicians, does not fix the sustainable growth rate (SGR) formula used to calculate Medicare payments to physicians. Nevertheless, the AOA and the AMA decided to support the health care bill, after concluding that the overall benefits of the reform package outweigh the drawbacks.

Agreeing with the AOA’s and the AMA’s support of the legislation, Steven Hollosi, DO, an emergency medicine resident in Charleston, W.Va., counts among those physicians gratified that health care reform passed, even if not completely satisfied with all of the political compromises. “People who practice medicine have a moral obligation to ensure universal health care,” contends Dr. Hollosi, a 2009-10 fellow of the Training in Policy Studies (TIPS) program offered by the New York College of Osteopathic Medicine at New York Institute of Technology (NYIT) in Old Westbury. “I’m for health care reform, and I like many aspects of the legislation.”

A number of DOs, however, are deeply disappointed by the legislation, and some dispute the need for health system reform.

An obstetrician and gynecologist from Grand Rapids, Mich., Laurence J. Burns, DO, laments the legislation as a lost opportunity because it doesn’t go far enough. “President Obama went about health care reform in the wrong way,” says Dr. Burns, who favors a single-payer system. “He should have had people with backgrounds in health care and economics come up with the plan. Instead he left this to politicians.”

Todd R. Fredricks, DO, a family physician from Amesville, Ohio, argues that the health care legislation represents an unacceptable expansion of federal power and is “an existential threat to state sovereignty,” noting that 20 states have filed lawsuits in federal court to stop the legislation’s mandate that individuals purchase health insurance.

“I am upset that the legislation gives the government more control over our daily lives, especially in light of the economic issues this country faces,” agrees Paul R. Ehrmann, DO, a family physician in Royal Oak, Mich. “I also have concerns about the process that brought this law into being—all of the horse trading and backroom deals—and about how this was shoved down the throats of the American people, when polls have shown that the majority of Americans oppose Obamacare.”

Dr. Ehrmann insists that the new law contains numerous provisions detrimental to patients and physician-patient relationships that will affect health care quality and access to care. “I’m very disenchanted with the AOA and the AMA for supporting the legislation,” Dr. Ehrmann says.

While these osteopathic physicians hold strong views on the health care legislation—the Patient Protection and Affordable Care Act of 2009, which originated in the U.S. Senate, and the Health Care Affordability and Reconciliation Act of 2010, which includes modifications made by the U.S. House of Representatives—other DOs are more measured in their appraisals.

“The legislation is a step in the right direction,” says Barbara Ross-Lee, DO, NYIT’s vice president for health sciences and medical affairs. Praising its emphasis on primary care, Dr. Ross-Lee is disappointed that the legislation doesn’t eliminate the caps on the number of Medicare-funded graduate medical education positions or enact comprehensive medical liability reform. But she believes the legislation “opens the door” to engaging health policymakers in addressing these and other issues in the future.

AOA 2nd Vice President Joseph M. Yasso Jr., DO, expressed similar sentiments the day the Patient Protection and Affordable Care Act became law. Acknowledging that the AOA has taken heat for supporting the reform package, with a few AOA members even vowing to destroy their membership cards, Dr. Yasso noted that the legislation can be “developed, fleshed out and improved upon.”

“This is far from over,” said Dr. Yasso during a March 23 teleconference of the AOA Bureau of State Government Affairs, which he chairs. “There is a lot more that can be done and accomplished. We are better off as an organization to be at the table.”

Noting that 94% of Americans will have health insurance thanks to the reforms, William H. Stager, DO, MPH, urges osteopathic physicians to be open-minded and actually read “a little bit” of the legislation rather than relying on the rhetoric of their favorite political party. “They would then see that the legislation has a lot of positives,” says Dr. Stager, who practices family medicine and osteopathic manipulative medicine in West Palm Beach, Fla. “That is why the AOA, the AMA and the AARP all supported it. The legislation isn’t perfect, but our health system cannot continue operating in a ‘business as usual’ mode.”

The financial arguments for expanding health insurance coverage are as strong as the moral considerations, Dr. Stager maintains, noting that the U.S. Department of Health and Human Services (HHS) estimates that individuals in United States who have health insurance pay approximately $1,000 in added premiums per year to offset the medical costs of the uninsured.

In an open letter to his colleagues, AOA President Larry A. Wickless, DO, defended the AOA’s decision to support the Patient Protection and Affordable Care Act. “This legislation makes fundamental and important changes in our health care system, includes numerous provisions beneficial to physicians, and—most importantly—has an opportunity to ensure improved health for our patients individually and our nation as a whole,” Dr. Wickless emphasized in the letter, after acknowledging that change can be difficult to accept.

“Certainly the bill is not ideal by anyone’s standards, but that is what politics and government are all about,” Richard D. Kimmel, DO, a cardiothoracic surgeon in Boca Raton, Fla., wrote to the AOA in response. “Compromise is never the solution for people who are closed-minded and tunnel-visioned.”

What physicians, patients can expect

According to the AOA, the health care legislation contains a number of provisions that will benefit physicians financially:

• All primary care physicians, as well as general surgeons who perform major procedures in health-professional shortage areas, will be eligible for 10% bonuses in Medicare payments from 2011 until 2016.
• In 2013 and 2014, Medicaid payments for evaluation and management services will be increased to at least 100% of Medicare payment rates.
• In September 2010, the “floor” on the work geographic practice cost index (GPCI) will be set at 1.0 for all localities. Medicare will begin making a separate adjustment for the practice expense portion of physician payments in 2010 and 2011. And beginning in 2011, Medicare will increase the practice expense GPCI adjustment for physicians in North Dakota, Montana, South Dakota, Utah and Wyoming to the national average.

In addition, starting in 2011, the HHS will award five-year demonstration grants to states to develop, implement and evaluate alternative medical liability reform initiatives, such as health courts and early-offer programs designed to settle claims before they go to court.

According to Dr. Ehrmann and Dr. Fredricks, such provisions don’t begin to make up for the big financial hit physicians will take in terms of higher personal income taxes and taxes on their practices—on top of the reimbursement cuts that will inevitably occur if the SGR formula is not corrected. Considered by the AOA, the AMA and other medical associations to be irreparably flawed primarily because it doesn’t accurately account for annual increases in physicians’ practice expenses, the SGR formula is expected to be addressed in separate legislation this summer.

Dr. Stager would have preferred “more solid” provisions related to medical liability reform. He questions why pilot projects are necessary when several states—most notably Texas—have already successfully implemented comprehensive tort reform, including caps on noneconomic damages.

But Dr. Stager agrees with the thrust of the health care package—to expand health insurance coverage to all Americans. And he is pleased that this year, several reform provisions benefiting patients will be implemented. Health insurance companies are now prohibited from denying coverage to children who have pre-existing conditions—a provision that will apply to adults as well in 2014. Insurers cannot place lifetime limits on how much they pay out to individual policyholders and cannot rescind coverage except in the case of fraud. And adult children up to the age of 26 are eligible for health insurance coverage under their parents’ or legal guardians’ insurance polices, a provision that could affect many young medical students.

“While there are things that could be better in the legislation, I am in favor of the main principle of covering people who have pre-existing conditions and not dropping people who become ill,” says Nader Raymond Ajluni, DO, a pediatrician in Des Moines, Iowa, who has voiced his support for health care reform to his professional peers as the secretary of the Iowa Chapter of the American Academy of Pediatrics.

Several provisions related to wellness and prevention will also be implemented in 2010 and 2011. This year, Medicaid will be required to cover tobacco cessation services for pregnant women, and private health insurance plans will be required to provide a minimum level of coverage without cost-sharing for preventives services. Next year, both Medicare and Medicaid will eliminate cost-sharing for all preventive services, and Medicare payments for these services will be increased to 100% of payment schedule rates.

In addition, the “doughnut hole” in Medicare Part D prescription drug coverage will start to narrow this year, with $250 rebates to Medicare beneficiaries whose prescription expenses reach the uncovered range of $2,700 to $6,150. This gap will be completely closed by 2020.

“Although the legislation doesn’t address the SGR formula, I like its emphasis on preventive care and prescription drug coverage,” says 2009-10 TIPS fellow Ashok Tyagi, DO, who is serving a pulmonary and critical care fellowship at Bostford Hospital in Farmington Hills, Mich.

Dr. Ehrmann concedes that he, too, likes the focus on preventive care and some of the restraints placed on health insurers. But, he contends, a major overhaul of the health system was not necessary to accomplish this, and the bad parts of the legislation far outweigh the good.

For example, Dr. Ehrmann is concerned that the legislation’s emphasis on outcomes research, also known as comparative effectiveness research, could diminish physicians’ autonomy in treating patients. “Based on the law as stated, medical decision-making may ultimately be directed by medically untrained bureaucrats rather than physicians,” Dr. Ehrmann asserts. The AOA, however, disagrees, noting that the law explicitly states that information gathered by the comparative-effectiveness body cannot be used for coverage or payment determinations.

Controversial mandates

Among the most controversial provisions of the legislation are the individual and employer mandates, which will be implemented in 2014.

Individuals who do not have employer-provided health insurance or other coverage will be required to purchase health insurance. The uninsured would pay a yearly penalty of $695 for each uninsured family member, up to a maximum of $2,085 or 2.5% of household income, whichever is greater.

Employers with more than 50 employees will be required to offer health insurance coverage to their employees or face annual penalties of $2,000 per full-time worker. Smaller employers will be eligible for tax credits if they provide coverage to employees—an aspect of the legislation that Dr. Hollosi particularly likes.

“The legislation appears to be a bonanza for insurance companies because people will be forced to buy insurance,” observes David E. Drake, DO, a psychiatrist in Des Moines, Iowa.

“Individual mandates are a good idea. By requiring everyone to have health insurance coverage, you are spreading the risk,” counters Dr. Tyagi, noting that this is what will enable health insurers to extend coverage to people with pre-existing conditions and do away with lifetime limits.

To make it easier for individuals and small businesses to afford health insurance, the legislation requires states to set up health insurance exchanges. In addition, individuals and businesses will be able to purchase health insurance outside of their own states. “This should foster market competition and allow prices to be affordable and competitive,” Dr. Hollosi predicts.

But Neil Spiegel, DO, who practices rehabilitation medicine in Rockville, Md., disagrees. “My guess is that there will be less choice,” Dr. Spiegel says, “because small insurers will find it difficult to compete with large companies, such as Aetna and Cigna. Eventually, the large insurance companies will buy out the smaller ones. And if patients have less choice, insurance companies will have greater pricing powers and increase premiums at a faster rate than before.”

Unforseeable future

The Congressional Budget Office (CBO) estimates that the reform legislation will ensure that 94% of Americans have access to quality affordable health care. But Dr. Spiegel has his doubts.

“Are more people covered now? Yes,” Dr. Spiegel concedes. “But will people have better access to care? I’m not so sure. You’re going to increase demand for medical services, but there won’t be enough physicians. This doesn’t make sense to me.”

Likewise, Dr. Ehrmann is convinced that the legislation will reduce patient access to care, citing as unfeasible a provision that requires states to ensure that Medicaid patients receive treatment. Especially given that many physicians don’t accept Medicaid, there are not enough physicians to provide the mandated care, he points out.

Although the CBO predicts that the reform legislation will reduce the federal deficit by $143 billion over the next 10 years, Dr. Spiegel is particularly worried about the costs of the health care overhaul. “This program has a lot of front-loaded money and back-loaded cost,” he contends, noting, for example, that if the SGR formula is fixed by separate legislation, that would cost more than $200 billion.

In addition, Dr. Spiegel anticipates that because of physician shortages, Medicaid patients will flock to emergency departments in even greater numbers than they do now, further increasing the costs of health system reform.

Dr. Spiegel, moreover, believes that the plan to cut Medicare by $500 billion will have a huge impact on physician reimbursement and patient care. But Dr. Stager disagrees, noting that this money will come out of Medicare Part C’s Medicare Advantage Plans, which have been reimbursing at rates 10-20% higher than standard Medicare rates.

Reforming the reform

While he has many complaints about the Patient Protection and Affordable Care Act, one of Dr. Fredricks’ biggest concerns is that the legislation levies additional fees on pharmaceutical companies, which “will stifle innovation and lead to mediocrity.” Given to quoting from 19th-century French historian Alexis de Tocqueville’s book Democracy in America, Dr. Fredricks waxes eloquent on how the greatness of the United States stems from self-determination and free enterprise.

Dr. Fredricks sees the health care legislation as a step toward the federal government’s “complete takeover of health care”—a single-payer system, in other words. He contends that the fees and restrictions imposed on insurance companies will by design drive them into bankruptcy. And once the federal government controls health care, he believes that the resulting reductions in physician pay will keep “the best and the brightest” from considering careers in medicine.

But Dr. Fredricks expects that free-market values will ultimately prevail when people start purchasing medical care from physicians on the black market to bypass long waits for government-funded care. American innovation and autonomy will eventually win out, he predicts.

Though enthusiastic about the health care reform legislation overall, Dr. Hollosi realizes it will have unintended consequences that, he says, “will need to be addressed one by one as each becomes apparent.”

“While the health care legislation contains some great ideas, we need to see how it plays out in reality,” adds Dr. Tyagi. “But I am cautiously optimistic about the legislation.”

Dr. Ehrmann does not share the optimism. “As the various provisions take effect, most Americans who currently have health insurance will be less satisfied with their coverage than they are now,” he predicts. “The health care legislation will have a deleterious effect on patients, physicians and the country as a whole.”

The president of the Florida Academy of Osteopathy, Dr. Stager urges physicians to stay involved in grassroots advocacy as the health care legislation is refined and “the reforms are reformed.”

“I’m going to continue to fight,” declares Dr. Ehrmann, noting that members of Congress should beware of voter anger. “I’m not giving up on my patients.”

But Iowa’s Dr. Ajluni sees much to be admired in the health care legislation and in the process of enacting the reforms. “It’s a tribute to democracy to have to include so many different points of view before reaching a conclusion,” he says.

“There are always things that could be better,” reflects Dr. Ajluni, who is a cousin of former AOA president Peter B. Ajluni, DO. “Whether a bureaucrat in the insurance industry or a bureaucrat in government makes a rule, there are always individual circumstances in which the rule may not apply. As long as policymakers have open minds and are willing to listen, I think this legislation will improve the nation’s health system.”