Thursday, June 18, 2015

What do doctors really think of Obamacare? (It’s not what critics have told you).

Anti-Obamacare critics often claim that “every” physician they know hates Obamacare. For instance, Pediatric neurosurgeon and GOP Presidential candidate Dr. Ben Carson told Fox News that “he's spoken to hundreds of doctors throughout the country about the Affordable Care Act, and not one of them ‘liked’ President Barack Obama's signature healthcare law.”
Doctors hate Obamacare, it’s alleged, because it authorizes government to “control” the practice of medicine and impose “rationing” of care, thereby harming patients.  The conservative Examiner website quotes a New Jersey family physician, Dr. John Tedeschi as saying, “Just as a guitar string has to be tuned, so does a person’s health to get the right tone. The government has taken away, or refocused the intelligence part of the tuning, and has just about destroyed the creative, or compassion component. Now, with Obamacare, we are left with an incompetent mechanism that does not have the best interest of the patient in mind.”  An ER physician quoted in the articles said that the “storm of patients [created by Obamacare] means when they can't get in to see a primary care physician, even more people will end up with me in the emergency room."

There is no question that some doctors (mainly conservatives) hate Obamacare, and if they were the only ones you talked to (like the ones who apparently talked to Dr. Carson), you might think that all doctors feel the same way. But the reality is that—surprise, surprise!—primary care physicians’ views are just like the rest of us, split by their partisan leanings.
A new survey by the respected Kaiser Family Foundation found that 87% of Democratic-leaning physicians view Obamacare favorably, while the exact same percentage of GOP-leaning physicians view it unfavorably. Independent doctors split 58% unfavorable to 42% favorable.  Because there were more GOP and independent physicians among the survey respondents, the overall breakdown of primary care physicians’ views on the ACA is  52% unfavorable to 48% favorable.  Yet only 26% of all primary care physicians viewed the law “very unfavorably. “  So it might be said that just one out of four primary care physicians “hate” Obamacare.

And a deeper dive into the survey results directly refutes the contention of anti-Obamacare doctors that the law is leading to poorer quality, physicians turning away patients, or longer waits for appointments:  

- Most primary care physicians say that quality has stayed the same: 59% said that their ability to provide high quality care to their patients has stayed about the same, while 20% said it has improved and 20% said it has gotten worse.
- More primary care physicians report that Medicaid expansion has had a more positive impact on quality than a negative one. “When asked more specifically about the expansion of Medicaid under the ACA, nearly four of 10 providers (36% of physicians and 39% of nurse practitioners and physician assistants) said the expansion has had a positive impact on providers’ ability to provide quality care to their patients (Table 7). About two of 10 said it has had a negative impact and the remainder said it has not made a difference or they are not sure.”
- Ease of getting same-day appointments is about the same as before the ACA. “Overall, about four of 10 primary care providers said almost all their patients who request a same- or next-day appointment can get one; another quarter said most of their patients can get such appointments” which is largely unchanged from 2009 and 2012.
- Most continue to accept new patients. “A large majority of primary care providers (83% of physicians, 93% of midlevel clinicians) said they are currently accepting new patients . . . A survey conducted in late 2011 through early 2012 found that 89 percent of primary care physicians were accepting new patients and 52 percent were accepting new Medicaid patients.  This indicates that while physicians’ rates of accepting new patients overall may have declined slightly since the ACA coverage expansions went into effect, acceptance rates for Medicaid have remained about the same.”

When asked specifically about their views on the impact of the Affordable Care Act on five dimensions, the ACA fared well, with one exception (costs to patients).

- Access to health care and insurance in the country overall: 48% positive, 12% no impact,  24% negative, and 14% not sure.
- Overall impact on practice: 31% reported no impact, 23% a positive  impact, 36% negative  and 9% not sure.
- Quality of care their patients receive: 50% reported no impact, 18% positive, 25% negative, and 6% not sure.
- Ability of the practice to meet patient demand: 44% no impact, 18% positive, 25% negative, and 10% not sure.
- Cost of health care for their patients: 17% no impact, 21% positive, 44% negative, and 16% not sure.

However, “physicians’ responses to questions that mention the ACA by name are deeply divided along party lines. For example, by a three-to-one margin, physicians who identify as Democrats are more likely to say the ACA has had a positive (44%) rather than a negative (15%) impact on their medical practice overall (Table 8). Republican physicians break in the opposite direction by about seven-to-one (57% negative, 8% positive).”

The survey also does not support the contention that the ACA is contributing to primary care physician dissatisfaction with practice and burn-out:

“Even though providers with different political affiliations do not share views about the Affordable Care Act, a large majority of primary care providers (83% of physicians and 93% of nurse practitioners and physician assistants)—both Republicans and Democrats—reported they are very or somewhat satisfied with their medical practice overall. The changing environment does not appear to be affecting overall provider satisfaction even among providers who see a larger share of Medicaid patients or work in Medicaid expansion states. Indeed, current satisfaction levels are slightly higher than what was reported by primary care physicians before the ACA. In 2012, 68 percent of primary care physicians reported they were very satisfied or satisfied with practicing medicine.”

Interestingly, Democratic physicians (56%) are more likely to recommend a career in primary care than Republicans (39%)  or Independents (40%).

I know that many conservative primary care doctors have a strong and principled objection to Obamacare, believing  passionately that it gives the government too much power and the physicians and their patients will be hurt as a result.  I (and ACP) may not agree with them, but I respect their views, and their right to make their case to their colleagues and to the public.

But the Kaiser Family Foundation survey shows us that the anti-Obamacare doctors do not represent the views and experience of most primary care doctors on the front lines, never mind “all” of them.  Doctors (at least those in primary care, who knows about surgeons?) clearly don’t “hate” Obamacare.  Rather, more of them see Obamacare as doing some good things, like improving access; and doing not as well on other things, like lowering costs to patients.  Much of what they do and see in their practices remains unchanged by it, for good or bad.

 And that strikes me about right, Obamacare is making many things better, but there is a lot more that needs to be done to improve quality and access, lower costs to patients, and sustain and support primary care.  Of course, such nuances do not make for as good a headline or political talking point as “Doctors Hate Obamacare.”

Today’s question: What is your reaction to the survey results on primary care physicians views on Obamacare?


Jay Larson MD said...

The political leaning and views towards Obamacare are not surprising. The survey was sent to about 1600 primary care physicians with 34% return rate. The 87% satisfaction with their practice suggests a skewed response from those who are doing okay with their practice compared to an average burnout rate of 50% with primary care physicians. Lets face it, the last thing a burned out physician will do is to fill out a survey about Obamacare. Physicians who are not burned out will have the capacity to see new patients and get patients in for acute appointments. The same can not be said for a burnout primary care physician.

Robert J. Sobel, M.D. said...

I'll even respond without my usual thorough read of your post. Jay, as usual, shows his prescience and perspective. How do we address burnout? Many of us are strained to the utmost and need protection from more distractions and mandates. Our health care environment is always evolving, but disruptive code changes and payment reforms aren't the solution. The professional service side should be respected and protected; the commodities (drugs and new technologies) should be smartly (I know, not easy) price regulated. By the way, great editorial in this week's NEJM on how we owe a debt of gratitude to the the lessons learned in the Civil War that helped shape American Medicine; historical perspective quite relevant at these times; only 150 years ago.

The problems of our public/private confusion are ever-present. The consolidated entities grow because they can afford representation and can obfuscate reality with good marketing/propaganda. Look at the fee-for-service haranguing. You've said we now have to make a choice on Medicare. Why did you support that? Do you really believe this can be done with overall favorable effect? Please, how many breathes and dreams do I have to put into the obvious: WE ARE NOT SHORT ON BUREAUCRACIES. LET'S DECONSTRUCT.

Thank you PCP for your voice. Harrison, thank you for an anecdote of addition. Bob, I understand the politics interface creates limits and deal-making. I just think we are getting a bit distracted from the make or break realities of private practice. Take on the waste of bureaucratic hassles, duplicative and coercive at times wellness programs, for-profit insurance that has shareholder conflict of interest, a Hatch-Waxman regime that is absurd and fails at savings as it balloons/alters the brands, and any other areas where you can protect the independent primary care giver.

We'll work hard for patients, but insurance companies are off spending on consultants and marketing and consolidation and can't afford to pay us our due. Thus, the patients pay even while drug prices do what I've always said they would.

Obamacare I is a step. Obamacare II would re-organize the private insurance industry and do its best to shrink/re-organize public programs that are fraud attractors and market distorters.