Tuesday, October 23, 2012

The Imaginary ObamaCare Bogeyman

Do you remember the good old days, say 2009, when doctors were able to spend as much time with a patient as needed,  when there weren’t any pre-authorization forms to fill out, when no one questioned your performance, and primary care doctors were paid what they are worth?  Of course you don’t, because it wasn’t that way.  But some physicians critical of ObamaCare have conjured up an imaginary version of the law,  one that blames it for everything they don’t like  about the healthcare system, like too much red tape and not enough pay, when really most of the things they don’t like pre-dated the law—sometimes by decades!  

 It is one thing to say that the ACA didn’t do enough to address the daily intrusions that that so aggravate physicians and patients alike, it is another thing to say that ObamaCare caused it all, and that somehow it would all go away if the ACA is repealed.

Here are some examples:

Mandate to adopt ICD-10 codes?  Nothing to do with ObamaCare.  The ICD-10 mandate was proposed in 2008  by Michael Leavitt, HHS Secretary under the George W. Bush administration, and the legal authority for it comes from the HIPAA legislation enacted in 1996.  The Obama administration delayed the rules implementation for another year.

Medicare pay for performance?  Started at least three years before ObamaCare. The first version of what is now called the Physicians’ Quality Reporting System began in 2007, three years before ObamaCare was enacted into law.  Yes, the ACA continues the program, but it certainly didn’t create it.

Primary care paid too little?  Nothing new here, except ObamaCare makes things a bit better.  Internists have been objecting to the undervaluation of primary care for decades. A 2006 ACP position paper talked about payment systems “Undervaluing the evaluation and management (E/M) clinical services that are predominately provided by primary care physicians.”   But it goes back much further than that. The first public policy that I wrote for internal medicine was a 1981 paper on improving payments for cognitive services,  written on behalf of the American Society of Internal Medicine,  my then-employer, which merged with ACP in 1998.  The fact is that ObamaCare at least starts to make things better for primary care, including an annual 10% Medicare primary care bonus  over five years, raising Medicaid payment rates to no less than Medicare’s in 2013 and 2014, and paying 500 advanced primary care practices soon to get an average of $20 per beneficiary per month for care coordination. 

Too much insurance company red tape?   A growing problem over many decades, but one that ObamaCare at least begins to take on by standardizing some insurance practices.  In 1990, the American Society of Internal Medicine wrote a paper titled America’s Health Care System: Strangling in Red Tape and defined the hassle factor as “The increasingly intrusive and often irrational administrative, regulatory review and paperwork burdens being placed on patients and physicians by the Medicare program and other insurers.”  It is a theme that ASIM (and certainly since the merger, ACP) have hit upon repeatedly in its advocacy for internal medicine.  ObamaCare  won’t make the hassle factor go away, and it may add some of its own aggravations, but it also impose fines on insurance companies if they don’t standardize and  streamline their enrollment, verification, electronic funds transfer, and authorization requirements to ease hassles on physicians and patients alike.

I get it that many physicians had expected (hoped) that health care reform legislation would have been mostly about getting rid of the “micro” issues that drive them crazy, when ObamaCare is mostly about reducing  barriers to people getting health insurance coverage.  This disconnect about what physicians find most bothersome about health care, and what ObamaCare is really intended to do, fuels the discontent that some physicians have with the ACA. But at the same time, a fair evaluation of ObamaCare would give it credit for what it does try to accomplish—provide tens of millions more Americans with health insurance. A fair evaluation would acknowledge that it does have provisions to reduce insurance company red tape and increase primary care reimbursements.  A fair evaluation would point out the need for more reform that addresses the daily intrusions on the patient-doctor relationship.

But it’s not fair to imagine that everything was hunky-dory for doctors before ObamaCare and that everything will be fine if it goes away.  It is not fair to engage in imaginary thinking that ObamaCare is the reason why doctors are drowning in red tape and primary care doctors aren’t getting paid enough.  Sure, let’s agree  that the ACA doesn’t do enough about these problems--even as it has some things that should help--but let’s not make ObamaCare the imaginary bogeyman for things that have frustrated doctors for many, many years, long before it became the law of the land, things that would still be with us if ObamaCare was repealed.

Today’s question: Do you think it is fair to blame ObamaCare for regulations, hassles, and unfair payment policies that existed long before it became law?


Jay Larson MD said...

"Do you remember the good old days, say 2009, when doctors were able to spend as much time with a patient as needed, when there weren’t any pre-authorization forms to fill out, when no one questioned your performance, and primary care doctors were paid what they are worth? ". Yes I remember those days but it was 1990 and not 2009.

Obamacare is not the cause of the issues raised, but unfortunately it does not fix the paperwork burden nor appropriately valuing cognitive visits and non face-face care either.

Steve Lucas said...

There are always unintended consequences when dealing with a piece of legislation this large. As noted in the last post, those outside the medical community will play a part in deciding the availability of insurance.


Steve Lucas