Certain provisions of the recently passed health care legislation have the potential to improve the quality of health care in this country, but many physicians are on tenterhooks as they wait to see what impact the landmark legislation ultimately will have on their practices and patients.

“There’s a lot to be done, and everyone is very anxious over this bill,” said Jerome Siegel, MD, clinical professor of medicine, Albert Einstein College of Medicine, New York City. “The whole thing won’t come out in its final form until 2014, but a lot of people will benefit in the next four to six months.”

What many consider to be among the highlights of the Patient Protection and Affordable Health Care Act, which was signed into effect March 24, 2010 by President Obama, is that it will expand health insurance to cover the 32 million Americans currently uninsured and that it includes a number of safeguards geared toward protecting patients. For example, by 2014, insurers will be prohibited from denying coverage or charging higher premiums to people with preexisting medical conditions, charging women higher premiums and putting lifetime dollar limits on insurance policies.

One aspect of the law that met with approval from health care professionals is the required coverage for high-risk patients with previous conditions, a provision that went into effect 90 days after the bill was signed.

“I frequently have young people [with no insurance] come to me with some bloody diarrhea, and I do a colonoscopy and find they have advanced Crohn’s disease,” said Scott Tenner, MD, MPH, director, Medical Education and Research, Division of Gastroenterology, Maimonides Medical Center, and associate professor of medicine, State University of New York Health Sciences Center, both in New York City. “For them to get health insurance, it was a nightmare. Also, without access, it’s hard for them to stay on the medications that will prevent complications. So this [part of the bill] is very important for us in gastroenterology,” he said.

Termination of the preexisting conditions waiver also will protect people who, for whatever reason, need to change insurance carriers—a not uncommon situation in this country.

“Let’s say you have breast cancer, it affects your work, you lose your job and you are unable to get coverage from BlueCross or United Health,” said Victor J. Zannis, MD, medical director, Breast Care Center for the Southwest, Phoenix. “The health care reform now forces insurance companies to ignore preexisting conditions. There are challenges to these companies trying to stay afloat, but making insurance more portable and less discriminatory is going to help everyone.”

The law contains some incentives and proposed incentives that may strengthen areas of weakness in health care, but it’s not clear at what cost. Physicians and patients alike have mixed feelings and opinions on what health care reform will eventually look like, partly because many provisions of the 2,400-page bill are not yet fully cooked.

“I don’t think any of us are experts on what’s going to happen. In fact, even the experts are not telling us what medical care is going to look like in this country five years from now,” Dr. Zannis said.

“There are tons of regulations that have not been fleshed out,” said Richard Reiling, MD, medical director, Presbyterian Cancer Center, Charlotte, N.C. “Now is the time to work with the regulatory agents and make sure the regulations at least conform to reality and make practice easier and better—I know this is going to be the American College of Surgeons’ [ACS] approach to the issues,” said Dr. Reiling, who has served as the ACS delegate to the American Medical Association’s (AMA) House of Delegates.

The three gastroenterology professional societies—the American College of Gastroenterology, the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy (ASGE)—basically fell in line with the AMA in supporting certain parts of the bill, such as extending health coverage to most Americans, while being critical of other components.

“There were things in the bill we did not support and were vocal against, such as the Independent Payment and Advisory Board [IPAB], and we were vocal about things that were noticeably absent from the law,” said Brian Jacobson, MD, MPH, associate professor of medicine at Boston University School of Medicine, and chair of the ASGE Health and Public Policy Committee. Dr. Jacobson cited specifically the law’s falling short on addressing tort reform and its failure to address the flawed Sustainable Growth Rate (SGR) formula.

Physicians Subject to Greater Scrutiny

Much of the current law focuses on quality initiatives—with an emphasis on cost containment and value—and many of the directives in the Patient Protection and Affordable Health Care Act have been in the making for quite some time.

“Health care reform as it affects physicians was already under way during the Bush administration,” said Dr. Jacobson. “A lot of people slam the Democrats, but frankly this stuff started in the last administration, and it’s just been kicked up a notch with this law.”

In 2005, the Centers for Medicare & Medicaid Services (CMS) published the quality roadmap, laying out an agenda for value-based purchasing. “They were tired of footing the bill for whatever doctors wanted to charge without having any proof of its value or worth,” Dr. Jacobson said. “This really launched a whole new way for the government to think about what physicians do, and to require that we show quality outcomes.”

The demand for quality led to the Tax Relief and Health Care Act of 2006, authorizing CMS to implement a quality reporting system, which they did by establishing the Physician Quality Reporting Initiative (PQRI). The government also started to track costs and found a lot of geographic variability, where high costs did not necessarily relate to better outcomes.

“PQRI is going to continue, but instead of being a bonus payment, it will be a negative payment update—1.5% initially and then 2% for everything in Medicare [for physicians not reporting in PQRI],” Dr. Jacobson said.

It is perhaps not surprising that as the government looks for ways to reel in the cost of health care while also trying to expand it, physicians likely are to come under more scrutiny than ever in regards to the cost and quality of service they provide. “We really are entering an era where they’re trying to track our costs and how much we comply with quality measures,” Dr. Jacobson said.

One component of the law under discussion is allowing insurance companies access to information on how much an individual physician charges.

“They want to know who costs a lot and who doesn’t across other insurers,” Dr. Jacobson said. “They will have access to that data now, and will be able to tier doctors according to how much they cost by diagnoses. They’re also looking at the quality aspects; if you cost a lot but your patients do great, that might be worth it.”

Additionally, as health care becomes increasingly electronic, information about physicians will be easier to track.

“They can see of all of your patients who are eligible for colorectal cancer screening and what percentage have had something done. If you comply well and screen your patients appropriately, you’re high quality,” Dr. Jacobson said.

With quality and cost being tracked, payers will be able to determine whether a physician is a level 1, 2 or 3 provider. And they may choose not to renew the contracts of level 3 providers.

The law also contains a provision for starting a demonstration project by 2019 that would incentivize Medicare beneficiaries to see only those doctors recognized as high quality by charging co-pays to patients who see lower-level providers. Benchmarking, too, will likely be a component of health care reform.

“Doctors will get reports so they can see how they compare with other doctors and have the ability to correct themselves,” Dr. Jacobson said.

In the name of comparative effectiveness research, the law has provisioned money for the creation of the Patient-Centered Outcomes Research Institute, an independent institution comprised of patients, health care professionals, government officials and other stakeholders to compare the clinical effectiveness of medical treatments. It is unclear what impact this will have on doctors and how they practice.

“This institute is supposed to focus on the clinical effectiveness and cost effectiveness of interventions we use and determine whether or not the government should pay for them,” Dr. Tenner explained. “This could be good or bad. Without any doubt, the strongest thing we do in gastroenterology is colorectal cancer screening, so I can see this institute being very supportive of ambulatory surgical centers as screening stations. But at the same time they’re going to be looking at things like virtual colonoscopy—could that be better for screening?”

A striking aspect of the law that troubles many is the authority and centralized power it hands to the secretary of Health and Human Services to evaluate the way doctors practice medicine, and to determine what stays and what goes.

“The secretary has the authority now to revalue what he or she sees as an overvalued entity; they could decide colonoscopy is overvalued,” Dr. Jacobson said. “This completely ignores the whole relative value units process. There can be an instant micromanipulation of what’s paid for [based on a decision made] by a non-physician secretary of Health and Human Services at the discretion of the president.”

Of the law’s more troubling provisions, the establishment of the IPAB has many physicians and patients deeply concerned. “This is a panel of 15 members whose job it will be to make recommendations to Congress about coverage and lowering costs of the Medicare program,” Dr. Tenner said.

IPAB’s proposals for lowering Medicare costs will become law unless Congress can establish an alternative cost-saving measure that will save as much money. “I think that’s the scariest part,” Dr. Jacobson said. “In the past, you could lobby Congress for changes. Now it basically comes down to one person in the Executive branch having all the authority.”

Many Doctors Disappointed, Discouraged

Although increasing access to health care seems like a good thing, access means more than coverage—it also means availability of trained physicians. Some estimate that more than half of the newly insured will be younger than 35 years old and in mostly good health, and that about one-third will enroll in Medicaid and likely use fewer services than those with private insurance. Still, many worry that the system will be strained by the influx of newly insured patients.

“We are concerned about access. There is a physician work shortage—and specifically a surgeon work shortage—and that’s something that I think will get worse in the future,” said Shawna Willey, MD, associate professor of surgery, and director, Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University, Washington.

Dr. Willey and others are concerned that as health care reform evolves, physicians may experience lower reimbursements along with increasing regulation. “It may make people decide that they don’t want to practice as long,” she said.

There is a provision in the bill that increases Medicare premiums to rural general surgeons working in underserved areas, but it is unclear how much of a difference that will make.

“To me, the problem is that you don’t make a bad job better by throwing money at it,” Dr. Reiling said, noting that in North Carolina, 25 counties currently have no general surgeon. “I think if we’re going to make effective changes to make primary care and general surgery more fulfilling, we’re going to have to include some kind of protection in terms of time off and ability to control your practice.”

Many physicians and the societies that represent them are deeply disappointed that the law does little or nothing to address SGR and tort reform.

“We’re looking at pretty significant cuts,” Dr. Reiling said. “I don’t totally understand why, but the fix [for the SGR problem] would cost about $250 billion downstream; if they’d put that in the bill it probably wouldn’t have passed.”

The law does have a provision awarding five-year grants to some states to develop alternatives to current tort litigation, but many doctors consider this little more than a nod toward acknowledging a problem, rather than a fix.

“Everybody has underplayed this,” Dr. Reiling said. “They don’t understand the true cost of the lack of support for tort reform. The psychological effect of liability is high, and a lot of doctors burn out because they’re worried about being sued and losing their life’s savings over something that may not even have been an error, but just a bad outcome.”

The law’s shortcoming on tort reform was a major concern to medical societies and to those doctors most vulnerable to being sued.

“The No. 1 lawsuit in America right now is for missed breast cancer,” Dr. Zannis said. “We all live under the worry that the one time we misread the exam or image, we could lose our practice because of large rewards given out by juries in this country. This is fueled by the tort system that we have, and we really wanted to see some solutions for that.”

The failure to address tort reform may be especially egregious if IPAB makes recommendations to drop coverage for services that physicians consider essential for quality care.

“There is concern that there may be an increase in liability if we aren’t doing everything we possibly can to, for instance, make a diagnosis of breast cancer,” Dr. Willey said. “We have many ways to try and diagnose breast cancer, but not all of them are cost effective.”

There may be some room in the ensuing months and years for various parties to voice their concerns about the law and attempt changes through technical correction bills, “where Congress can basically change the law when something’s wrong,” Dr. Jacobson said.

“For instance, they may be asking for certain things within unreachable timelines. But I think the largest portions of the law are here to stay.”