Implementing the Affordable Care Act will increase physician tension

It’s really quite an ancient debate: 400 to 500 years before the birth of Christ, on the island of Kos (home of Hippocrates) originates the myth of Aesculapius, god of healing, son of Apollo and the nymph Coronis.

As is not unusual in Greek mythology, Coronis meets a violent death, but the infant Aesculapius is saved. He is raised by a wise centaur, becomes skilled in healing arts, and succeeds in bringing a patient back to life. This act threatens Zeus and the god’s ownership of immortality, so Aesculapius is promptly placed among the stars as Ophiuchus, the serpent-bearer.

It is the serpent-symbol of medicine (caduceus) that results.

The children of Aesculapius included his goddess daughters Hygeia and Panacea who were the symbols of hygiene and healing. These female figures, especially Hygeia, focused on prevention and public health, which created a tension with and for their father and was characterized by George Sheehan, MD, in 1984:

Medicine is divided into two camps: public health and private practice; the disciples of Hygeia, goddess of health, and those of Aesculapius, god of medicine; those who would prevent death and disease and those intent on curing it. One camp is concerned with humanity; the other with individuals.

It is conceivable to view the American healthcare debate and the resultant reform legislation, the Patient Protection and Affordable Care Act (commonly the ACA) as an extension of this ancient dialogue.

Most Americans feel strongly about the ACA, and, depending upon which side’s survey one reads, are either 75% in opposition (Rasmussen, 2011) or 80% in favor (Franken, 2011). Professor Regina Herzlinger, of the Harvard School of Business, asserts that:

The U.S. healthcare system is in the midst of a ferocious war. The prize is unimaginably huge — $2 trillion, about the size of the economy of China — and the outcome will affect the health and welfare of hundreds of millions of people. Four armies are battling to gain control: the health insurers, hospitals, government, and doctors. Yet you and I, the people who use the healthcare system and who pay for all of it, are not even combatants. And the doctors, the group whose interests are most closely aligned with our welfare, are losing the war.

The recent and ongoing federal budget crisis has refocused the issues surrounding the ACA and rekindled uncertainties regarding implementation.

In financially challenging times, the focus really ought to be on how to solve the finances of accessibility to care for everyone concerned without bankrupting the nation, not just a program for some of the stakeholders.

Kuttner describes the “extreme failure of the U.S. to contain medical costs” as a result of our primarily pervasive commercialization, from for-profit insurance, pharmaceuticals, specialty hospitals, and physicians … indeed all the players with profit-maximizing behavior.”

The ACA is an enabling act that sets up the infrastructure responsible for implementation, which requires, at last count, some 159 new federal administrative agencies. These agencies set up the administrative codes and regulations. So far, an estimated 6,000+ pages of rules and regulations have been written to implement the 907-page law.

Millions of Americans will witness a change in how they access healthcare services. ACA implementation and its impact are staged, so changes are quite deliberate and gradual, but they will be dramatic.

None of these reforms, though, are without significant and knowledgeable detractors, and not all of these voices are irrational naysayers.

At present, our fiscal crisis dominates the narrative pro or con. Eliminating “waste” in healthcare has taken the debate to extreme levels. “Identification of waste is difficult,” asserts Victor Fuchs, PhD, in JAMA, “but eliminating it is more difficult. Every dollar of waste is income to some individual or organization.”

Healthcare economist Uwe Reinhardt of Princeton writes: “physicians will always behave so as to maximize the net hourly income that they can extract from the practice of medicine.” An article by Baker states that physician fee-for-service charges are influenced by market penetration of managed care, which reduces the intensity and cost of medical treatments.

How to contain and control physician fiscal comportment have been structural, instrumental, and provocative aspects of the discussion, and clearly an embedded goal of the ACA.

Seeing the American professional as the culpable and avaricious agent of expensive medical care, exploiting diseases with costly and unnecessary procedures under the guise of medical necessity but actually little more than instruments of personal greed in a bloated fee-for-service system has been the implied cynical message.

Indeed, these exigencies are considered the addressable correctable violations of the public’s trust that necessitate global healthcare reform.

William Hsiao, PhD, writing in the New England Journal of Medicine calls for a single-payer solution to “eliminate the perverse incentives inherent in the fee-for-service system,” and joins the chorus of voices that characterizes all American healthcare as “fragmented.”

According to Hsiao, “savings of 8% in healthcare expenditures through administrative simplification and consolidation, plus another 5% by reducing fraud and abuse” were produced by his computer models.

Haywood and Kosel describe how “to stem the spiraling costs of the Medicare program and the need to shift the healthcare system from volume-based to value-based rewards” using the Accountable Care Organization (ACO) model. Seton Hall Law School’s Jordan Cohen declares that “CMS got the Medicare Shared Savings Program (MSSP) proposed rule largely right, but not because of the actual ‘shared savings’ that the ACO model is commonly associated with. Rather, the MSSP will usher in a shift from the practice of medicine as primarily an art, to the practice of medicine as primarily a science.”

Effectively, the implication that fee-for-service private practice must end in order for ACA healthcare reform to proceed is undeniably clear. For that, a 429-page rule from the Centers for Medicare and Medicaid (CMS) was required.

Loosely defined, ACOs will be groups of providers working together to treat a population of patients (usually about 5,000), and splitting the payments providers receive based on the compliance acceptability standards for the care they provide. The Medicare Independent Payment Advisory Commission recommends the rewards-and-penalties approach for reimbursement.

This carrot-and-stick approach to professional reimbursement – complete with the possibility of fraud or felony charges — is what distinguishes the ACO from its ancestor, the HMO. Once a professional is so targeted, loss of licensure, public censure, payback to CMS, not just loss or reduction of fees, but career-ending punishments and a gauntlet of judicial troubles may follow.

Voices raised in opposition to this protocol to control provider (physician) fiscal comportment point to failures in the previous HMO models to contain costs: that the model became top-heavy with bureaucracy and administrative burden at the expense of patient care; that reduction of the working professional’s autonomy and trained medical objectivity because of intensified scrutiny and the artifice of third-party approval for medically-indicated interventions would complicate care plus doom the model.

Further observations include the likelihood that the field of professionals would narrow or reduce significantly in the shadow of big government and “the stranger at the bedside.” Limitations on patient autonomy are tangible and critical intrusions. These are just several of many observations and objections.

Without parsing the polemics of the debate on either side of this discussion, the probability that there will be modification in the delivery of medical care in the U.S., the financing of that care, and the inevitable credit (or blame) for the changes represent the new norm.

It is likely that the changes will be welcomed by some and resisted by others — or even acceptably neutral to many — no matter which side of the discussion one champions. But we have an enabling piece of legislation in place, signed by the president, with an extant and growing body of administrative code.

Even if defunded, the American public will proceed to adjust. The format and extent of change does remain to be seen.

Here’s the caveat, according to Sullivan writing in the Hastings Center Report in 1999:

Successful American social reform has always blended or at least balanced moral and political concerns with the demands of economic efficiency. The blend or balance, however, works only when it is understood by the majority as clearly in the national interest. The Clinton (1992) effort at healthcare reform lost because the cause of reform became polarized …

Clearly it is time to form a societal consensus and an inclusive solution.

Perhaps it is time for Hygeia and Aesculapius to set aside personalities, accusatory differences, irreconcilability, irrationality, swords, and daggers … and get along.

They need each other.

Jeffrey Hall Dobken is an assistant clinical professor of pediatric immunology and allergy, and certified bioethicist at Weill Cornell School of Medicine in New York City.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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