Healthcare Reform a Work in Progress, Say Medical Societies

March 22, 2011

March 22, 2011 — Supporters of healthcare reform in organized medicine continue to defend the broad outlines of the Affordable Care Act (ACA) as it turns 1 year old tomorrow, but consider it a work in progress that warrants deletions, revisions, and insertions.

"There's a lot in this legislation in terms of expanding insurance coverage and improving the quality of care that will take us to a better place," said Cecil Wilson, MD, president of the American Medical Association (AMA). "Where we are now is not a good place."

Dr. Cecil Wilson

"When you go through the law, so much of it will benefit patients," added Charles Cutler, MD, chair of the Board of Governors of the American College of Physicians (ACP). But there is "need for adjustment around the edges."

Near the top of almost everyone's adjustment list is the Independent Payment Advisory Board (IPAB), created by the ACA to control Medicare spending. IPAB's job will be to enforce spending targets similar to those set by Medicare's sustainable growth rate (SGR) formula — and that is problematic, said the AMA's Dr. Wilson.

"It could be a double jeopardy for physicians — an IPAB cut on top of an SGR cut," he said.

Dr. Charles Cutler

Furthermore, the IPAB wields too much power as a collection of unelected officials, noted the ACP's Dr. Cutler. "Congress should have the final say on physician pay." And organized medicine dislikes how IPAB cuts will take effect for physicians in 2015, but not until 2019 for hospitals.

Another leading sore spot is the provision requiring all businesses, including medical practices, to file federal tax form 1099 with the Internal Revenue Service beginning in 2012 if they buy $600 or more worth of goods or services in a given year from any vendor. Previously, the form was needed only for services, and only when they were supplied by unincorporated businesses, such as sole proprietors. The intent is to identify more taxable vendor revenue, but the business community, including organized medicine, protests that compliance will cost too much in time and money.

Democrats and Republicans alike proclaim they want to abolish this paperwork duty, but they disagree on how to make up the revenue that would be lost with repeal.

Physicians also lament the lack of strong medical liability reforms in the ACA, such as a cap on noneconomic (pain and suffering) damages. Instead, the ACA invests in experiments to resolve malpractice claims outside the courtroom in a speedy, less adversarial manner.

"We'll pursue tort reform as far as we can," said Jack Lewin, MD, chief executive officer of the American College of Cardiology (ACC). "We think caps are the most powerful mechanism [for tort reform]." His society and others are rallying behind a House bill called the Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act, which would limit noneconomic damages to $250,000 and impose other restrictions to discourage frivolous lawsuits and jackpot jury awards.

Dr. Jack Lewin

Perhaps more than anything, organized medicine wants the next stage of healthcare reform to include a permanent solution to the Medicare reimbursement crisis. Such a "doc fix," as it is called on Capitol Hill, was included in an early version of reform legislation but was later stripped out by congressional Democrats because of its steep cost.

No Government Takeover of Healthcare

Physicians leaders seeking to revise healthcare reform also defend the new law against opponents who would junk it entirely. Those opponents, both inside and outside of medicine, portray the ACA as a government takeover of healthcare. That is the position, for example, of a group called the Coalition of State Medical and National Specialty Societies, which represents some 85,000 physicians.

"Our coalition does not believe that more government intervention is healthy for our patients," spokesperson M. Todd Williamson, MD, a neurologist from Lawrenceville, Georgia, told Medscape Medical News.

The AMA's Dr. Wilson does not buy the takeover talk.

"The ACA provides people with funds so they can buy insurance in the private market," Dr. Wilson said. "Private insurers will compete for these individuals. I would suggest the ACA will stimulate the private market."

"Private insurers are part of the plan," said Roland Goertz, MD, president of the American Academy of Family Physicians, adding, "I don't believe you'll see a government takeover of medicine in this country."

The ACP's Dr. Cutler turns the takeover argument on its head.

"Medical care now is highly regulated by private plans," said Dr. Cutler. "I think there is less regulation by the government. Virtually every CT [computed tomography] scan has to be preapproved by private insurers. If you have traditional Medicare, you can go [directly] to an imaging center and get your scan."

For his part, Dr. Lewin at the ACC sounds a more cautionary note.

"The government is already financing and therefore overseeing over 50% of US healthcare," he said, referring to the Medicare and Medicaid programs. "We need a private sector to compete with government. It's one of the profession's responsibilities to make sure this balance remains."

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