Is the Healthcare Reform Bill Bad Medicine for Physicians and Patients?

On Sunday, the House of Representatives voted 219 to 212 to approve the Senate version of the health reform bill, H.R. 3590. No Republicans voted for passage; 34 Democrats also voted against the measure. According to the Washington Post, the House late Sunday also “approved a package of fixes to the legislation that will face a potentially rocky journey through the Senate this week,” otherwise known as reconciliation. The version to be voted on by the Senate includes “more generous subsidies to people eligible for federal help buying insurance,” funding to close the “doughnut hole” in Medicare prescription drug coverage, a delay until 2018 on the 40% excise tax on employer-provided “Cadillac insurance policies,” and a 3.8% Medicare tax on investment income for the top level of earners.

Lost in all the hoopla surrounding backroom wheeling and dealing, arcane parliamentary procedures, rudeness on the House floor, and who voted for what amendment leading up to passage of the healthcare reform bill has been the response from the physician community, which has been decidedly mixed.

The American Medical Association said that “passage of health system reform by the U.S. House of Representatives today is an important step toward providing coverage to all Americans and improving our nation’s health system.” The AMA also said that, while the bill isn’t perfect,” by extending health coverage to “tens of millions of uninsured, improving competition and choice in the insurance marketplace, promoting prevention and wellness, reducing administrative burdens, and promoting clinical comparative effectiveness research, this bill will help patients and the physicians who care for them. There are increased payments for primary care physicians caring for Medicaid patients and bonus payments for physicians in underserved areas.” The AMA posted a document last week that provides answers to several frequently asked questions about healthcare reform legislation.

The American Academy of Family Physicians has also praised the passing of the reform bill, calling it “a comprehensive health care reform bill that will expand coverage to millions of people and move the country toward a more primary care-based health care system.” AAFP president Lori Heim, MD, in a prepared statement, said that “although the bill is not perfect” and that “this legislation is the beginning,” as a result of Congress passing this bill, “Americans can look forward to health security because they soon will have the chance to buy health insurance that meets their needs without emptying their bank accounts. It opens the door to a reformed health delivery system by paying a bonus for primary care services, which sends a message acknowledging the value of primary care physicians. It also encourages broader testing of the patient-centered medical home and focuses on paying for quality rather than quantity. It begins to invest in the primary care physician workforce as the foundation of a more efficient and effective health care system for this country.”

Not every professional group and society is in favor of the new legislation. The Association of American Physicians and Surgeons opposes the reform bill for a litany of reasons, saying it will “force Americans into expensive health plans that they don’t want,” destroy “economical true insurance policies that Americans DO want,” and most importantly, it will impose “a massive, unaccountable bureaucracy between patients and their physicians.”

The group Physicians for a National Health Plan said that this bill is akin to “seeing aspirin dispensed for the treatment of cancer,” noting that it will still leave 23 million Americans uninsured; “drain about $40 billion from Medicare payments to safety-net hospitals, threatening the care of the tens of millions who will remain uninsured;” and will cause healthcare costs “to skyrocket, as the experience with the Massachusetts plan (after which this bill is patterned) amply demonstrates.”

Physicians United for Patients -- which represents the views of more than a dozen medical societies, including, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Otolaryngology - Head and Neck Surgery, the American Association of Hip and Knee Surgeons, the American Association of Neurological Surgeons, the American Association of Orthopaedic Surgeons, the American Osteopathic Academy of Orthopedics, the American Shoulder and Elbow Surgeons, the American Society of Breast Surgeons, the American Society of Cataract and Refractive Surgery, the Arthroscopy Association of North America, the Congress of Neurological Surgeons, the National Association of Spine Specialists, the Orthopaedic Trauma Association, and the Pediatric Orthopaedic Society of North America -- has called the bill “bad medicine for patients.”

The American College of Physicians released a statement today that said the reform legislation includes “some important first steps to begin to reverse a catastrophic shortage of primary care physicians,” but cautioned that “more will need to be done to ensure that patients will have timely access to care by an internist or other primary care physician of their choice.” Among other proposals, the ACP called on Congress to enact additional reforms to “support the value of care provided by internists in a Patient-Centered Medical Home, to make permanent improvements in Medicare and Medicaid payments, to reduce the costs of defensive medicine, and to end the permanent cycle of Medicare (SGR) physician payment cuts.”

Is the bill bad medicine for primary care physicians and other specialties, too? The always insightful and pithy Dr. Rich of the Covert Rationing Blog says that physicians should look to the reform bill that passed that Senate back in December, as “that is the bill which will actually become the law of the land.” They may not like what they find there, as Dr. Rich notes that the Senate’s approach to ameliorating the chronic shortage of primary care physicians in this country is to redefine “PCP” to mean not “primary care physician” but rather “primary care practitioner,” which will now include nurse practitioners, physician assistants, and clinical nurse specialists. Thus, says Dr. Rich, “Having painstakingly reduced you unfortunate practitioners of primary care medicine to tools of the state - whose job is to follow the guidelines and place chits on the checklists which are handed down from on high, and to fill out the electronic forms which are designed not to advance patient care but to convenience the healthcare accountants who will thereby judge your “quality” - it is only natural for the central authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses - who can be “trained up” much more rapidly than you, who will work for much less money than you, and who (they think) will be much less recalcitrant about following handed-down directives than you - will fill the gap. And you, doctor, can go pound salt.”

Kevin Pho, MD, says that “much more work needs to be done to ensure that there is enough primary care access to meet the needs of the 30-35 million newly insured patients.” By way of example, he notes that Massachusetts, “the only state that offers universal coverage,” suffers from “some of the worst primary care wait times in the country despite having the highest concentration of doctors nationwide.”

What’s actually in the healthcare reform bill?

This article from Reuters does a good job of explaining when specific provision in the bill will take effect. Within the first year of enactment, the bill calls for:

• Banning insurance companies from dropping coverage for people when they get sick and excluding kids with pre-existing conditions, restricting annual coverage limits, and eliminating lifetime coverage limits
• Allowing adult children (up to the age of 26) to stay on their parents’ health plans
• Creating a new program to provide coverage for uninsured adults who have pre-existing conditions (program expires in 2014 when insurance exchanges begin operating)
• A $250 rebate for Medicare drug beneficiaries who fall into the "doughnut hole,” with provisions to eventually close the coverage gap entirely
• Tax credits for some small businesses to help provide coverage for workers

The article goes on to detail new programs and requirements that will also be enacted in 2011-2018. For more, see this New York Times summary of the maneuvering leading up to the passage of the bill.

HCPLive wants to know:

What is your reaction to the passage of this bill? What will it mean for you and your patients?

Assuming you don’t want to scrap this legislation entirely, what would you change about the current bill? What does it leave out? What does it get wrong? Also, what does it get right?

If you do want to scrap the whole thing and start over, what would your ideal bill look like? What is the most important thing we could do right now to improve healthcare delivery in this country?

Do you feel as if your professional society and other national physician leadership groups represented your interests in this process? If not, what do you plan to do now? Leave a comment below and tell us what you think!

Coverage from our sister website Pharmacy Times:Pharmacy Provisions Intact in Healthcare Reform Bill