April 7, 2010 — The enactment of landmark healthcare reform last month shone a spotlight on deep divisions not only within Congress and the American public but also within organized medicine.
Where medical societies stood on the legislation largely hinged on the answer to the question "What's in it for me?" And the answer to that question depended on whether a given society represented surgical specialists or primary care physicians.
At first glance, the split may not be so apparent. The American Medical Association (AMA), often called "the house of medicine" because it purports to represent all physicians in all specialties, had given qualified support to the legislation. Its stance was a new leaf for an organization that had staunchly opposed major healthcare reform initiatives — think Medicare — going back for decades.
Other major medical societies that applauded the passage of reform legislation with varying degrees of enthusiasm include the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Cardiology, the American Psychiatric Association, and the American Osteopathic Association. By and large, these groups praised the law for extending insurance coverage to 32 million more Americans over 10 years and imposing pro-patient regulations on private insurers, who will no longer be able to deny someone a policy on the basis of preexisting conditions.
"We see this as a good platform for providing people with quality, affordable healthcare," American Academy of Family Physicians President Lori Heim, MD, told Medscape Medical News.
However, the primary care hue of most of these pro-reform groups is telling. Surgeons, by and large, had urged the House to vote down the healthcare legislation that it ultimately approved on March 21. A coalition of 23 medical societies representing 240,000 surgeons and anesthesiologists sent a letter to House Speaker Nancy Pelosi (D-CA) shortly before the vote, stating that the bill failed to build a solid foundation for reform. Signatories included the American College of Surgeons, the American Congress of Obstetricians and Gynecologists, the American Association of Orthopaedic Surgeons, and the American Urological Association.
Some of the major discontents of this coalition were shared by the AMA and other societies that had rallied behind the legislation. The absence of a repeal of the notorious sustainable growth rate formula, which led to a 21.2% Medicare pay cut on April 1, ranked high on the list, as did the creation of an Independent Payment Advisory Board for Medicare that critics consider unaccountable for its decisions. Other gripes were the lack of any major tort reform, such as caps on pain-and-suffering damages in malpractice cases, and penalties for physicians who do not participate in Medicare's Physician Quality Reporting Initiative.
Although the AMA and its allies vowed to work with Congress to correct these sins of omission and commission, the surgical societies concluded that the cons of healthcare reform outweighed the pros, and lobbied against the legislation.
Bonus for Primary Care Physicians, But Not for Most Surgeons
Medical societies representing primary care physicians tended to support healthcare reform more than their surgical counterparts because they stood to gain more from it, experts say.
"There were many things to help primary care physicians, and not very many things to help surgeons," said Kristen Hedstrom, assistant director of legislative affairs for the American College of Surgeons. It is not as if surgeons didn't want to give an economic break to beleaguered internists, family physicians, and pediatricians, Hedstrom explained. Surgeons just wanted a break for themselves as well.
For one thing, the new law attempts to expand a short-handed primary care workforce, which will be further strained by millions of newly insured patients. It pumps more money into scholarships and loan repayment programs for medical students headed into primary care fields, increases the number of residency-training slots for them, and provides economic incentives to practice in underserved areas.
In addition to those carrots, there is a 10% Medicare bonus for primary care physicians and general surgeons in medically underserved areas from 2011 to 2015. However, there is no 10% bonus for an orthopaedic surgeon in suburban Chicago or a urologist in Seattle. Likewise, general internists, pediatricians, and family physicians will see their Medicaid reimbursement rise to Medicare levels in 2013 and 2014 for evaluation and management services and vaccine administration.
"That's a very significant increase," Princeton University healthcare economist Uwe Reinhardt, PhD, told Medscape Medical News. "This bill is friendly to primary care physicians, who have always felt underpaid."
Surgeons Stand to Face Pay Cuts in the Long Term
Other reimbursement advantages accruing to primary care physicians are more subtle than a mere pay hike, said Paul Ginsburg, PhD, president of the Center for Studying Health System Change. The reform law, for example, promotes the medical-home practice model in which a primary care physician receives extra money for coordinating a patient's care.
Another new reimbursement model in the law is the accountable care organization (ACO). The Medicare Payment Advisory Commission defines an ACO as an alliance of primary care and specialist physicians and at least 1 hospital that assumes joint responsibility for meeting performance measures for quality and cost. The new law allows ACOs to share in any cost savings they achieved in treating Medicare patients. Again, a key idea here is coordinated care.
In an ACO, said Dr. Ginsburg, "primary care physicians probably see themselves as becoming a more critical part of the delivery system." As such, they would reprise the central role they played in the heyday of managed care in the early to mid-1990s, "which really enhanced the income of primary care doctors," Dr. Ginsburg said. And by effectively managing chronic diseases like diabetes and hypertension, he said, ACOs can reduce hospitalizations and surgeries, which bodes ill for surgeon income.
To be sure, the new healthcare reform law gives some consideration to what surgeons earn. It's written so that the Medicare bonus for primary care physicians will not be funded by trimming pay for other specialties. However, in the long-term, the handwriting on the wall is reduced reimbursement for surgeons, noted Dr. Reinhardt.
"They know ultimately that their fees will be cut," he said.
The conflicting positions that primary care and surgical societies took on healthcare reform reflect a long-standing rift over these kind of reimbursement issues, said cardiologist Thomas Sullivan, MD, a former president of the Massachusetts Medical Society.
"It's an old battle between procedurally oriented and cognitively oriented physicians, and it's heating up, partly because the government recognizes there's a major shortage of primary care physicians," said Dr. Sullivan. "Surgeons are afraid that primary care will be promoted at their expense."
State Medical Societies Parted Ways Over Reform Legislation
The division in organized medicine over healthcare reform also expressed itself on a state level for reasons that went beyond specialty squabbles. Some state medical societies such as those in Minnesota, Pennsylvania, Massachusetts, and California took a cue from the AMA and hailed the bill's passage as a good first step, or progress, despite its shortcomings.
"It is difficult for the Pennsylvania Medical Society to speak either glowingly or disparaging of the health system reform package," society president James Goodyear, MD, stated in a press release.
Mario Motta, MD, president of the Massachusetts Medical Society, was a bit more positive.
"Even though the bill is far from perfect, our country is much better off with the legislation than without it," Dr. Motta said.
In contrast, at least 10 state medical societies — those in Alabama, Delaware, Florida, Georgia, Kansas, New Jersey, Oklahoma, South Carolina, Tennessee, and Texas — went on record as opposing the bill. The reasons are well summarized in a statement from William Fleming III, MD, the president of the Texas Medical Association.
"[Congress] passed a bill that does nothing to fix glaring problems in our current healthcare system," stated Dr. Fleming. "Instead, it saddles Texans with higher costs, higher taxes, more red tape and more bureaucracy. We believe the bill's unaffordable health system reforms, piled on top of a crumbling Medicare foundation, will create even more dire consequences for all."
Whether a state was politically red or blue appeared to have some bearing on which way its medical society went. President Barack Obama carried California, Massachusetts, Minnesota, and Pennsylvania in 2008, for example, and the medical societies in those blue states also leaned toward the healthcare reform law. Medical societies that came out against "Obamacare" tended to be in states won by Sen. John McCain (R-AZ). Texas and Georgia were prime red examples. However, organized medicine in the blue states of Florida, New Jersey, and Delaware broke this political pattern by siding with reform opponents.
To Dr. Sullivan, how state medical societies lined up on this historic reordering of the healthcare system reflected the inherent diversity in the profession.
"We're like the rest of the United States, and Congress," he said.