Brace yourselves. Wear comfortable shoes. Like it or not, you’re about to participate in a paradigm shift in health care. A two-page article tucked into last week’s Journal of the American Medical Association (JAMA) reporting on the results of physician surveys about the Affordable Care Act reflects a genuine paradigm shift.
First, let’s clarify the Affordable Care Act (ACA), currently being wrestled over in the Supreme Court. Despite its legendary length, JAMA cites four key points:
- It will provide health insurance for the 30 million uninsured Americans. Everyone, no matter what their income, will have access to health insurance that allows them access to care. I should never again have to hear the gut-wrenching sentence, “I’m so sorry. I stopped all my medicines. I lost my job and my health insurance and my family had to eat.”
- It will standardize health insurance coverage so that the current patchwork mess of variable deductibles, under-insurance, and endless denials of benefits will come to a halt. The concept of “pre-existing conditions” disappears. I will never have to hear about someone being denied insurance because they had back pain a decade earlier.
- It will improve the quality of care by redesigning the healthcare system so that it financially rewards physicians for providing the best care for patients. It does so by tracking practices using measurable goals (percentage of smokers counseled in smoking cessation, women receiving Pap smears, etc.). This is nothing like the current fee-for-service system, which ignores quality and rewards high volume, such as seeing patients quickly and performing more invasive tests and surgical procedures than needed
- It will reverse the declining numbers of primary care physicians by boosting their reimbursement rates while holding steady or reducing the high dollar amounts paid to specialists.
So if this is the ACA, it’s reasonable to ask what doctors think about having the ACA foisted on them. The answer is just as you’d expect. It depends on what group of physicians you ask.
Among those well-established in practice, age 40 and up, a small sampling of 500 physicians showed they generally were split: 44% felt the ACA a was serious step in the wrong direction, 44% felt it was beneficial for all Americans, and 12% were undecided. In a larger sampling of about 5,000 physicians, 58% opposed and 42% supported passage of the ACA. Not surprisingly, primary care physicians were more likely to be in favor than specialists.
Interestingly, although many of the physicians opposed to the ACA itself had numerous complaints about our current system of reimbursement, they’d managed to survive and build successful practices. Their answer seemed to reflect the adage “better the devil you know than the devil you don’t.”
But when opposition to anything starts to disappear, change occurs. Younger upstarts question the “wisdom” of their elders and the most vociferous of these elders inevitably get older, retire, and go silent.
And with the power of the young, genuine change occurs
I myself once witnessed a small version of this when I presented to the decidedly older members of an Illinois State Medical Society committee my personal support for the licensing of acupuncture. Their approval was necessary for the state legislature to go forward and create licensing.
Yet despite being presented with good clinical evidence about the benefits of acupuncture, these doctors, all well into their 60s and 70s, were quite hostile, referring to it as “quackupuncture.” It was obvious they’d barely glanced at the clinical material I’d given them. They gave licensing a quick thumbs-down. “More evidence needed,” I was told, clearly a delaying tactic since about 30 acupuncture articles were stacked in front of each of them.
One year later, I was back again and this time there were several new and definitely younger committee members. I was asked to explain some details from the research, and when one member said, “My wife swears by her acupuncturist. I wish there were a few more in my town,” I knew I was witnessing a paradigm shift. At that very meeting the committee voted to approve licensure for traditional Chinese medicine, including acupuncture.
The JAMA piece, short version by age group
A distillation of what the JAMA article reported looks a little different when you separate physician responders for and against the ACA by age:
- Among practicing physicians 40 and younger, 47% (that’s almost half of all doctors) believe the ACA is a good place to begin, with just 36% opposed to it.
- Medical students and residents are even more optimistic about the ACA, with 59% in favor of its passage, 15% in favor of repealing it, and 26% undecided. Interestingly, among the 15% who wish it repealed, a full third of this group wants it repealed because it doesn’t go far enough to reform the health care system. These are America’s future doctors and they want all Americans to have equal access to the very health care they’ll be delivering.
A final point of the survey is worth noting. You might think that working in a healthcare system that theoretically could end up as one massive government bureaucracy would discourage even the most dedicated from wanting to be a doctor, but actually just the opposite seems to be the case. After several years of flat application rates to medical schools, with the advent of the ACA the numbers of new applicants have increased by an average of 3% a year.
Additionally, each year has seen an increase in applicants to residencies in the primary care specialties, most notably in family practice, which increased by 21% last year.
So in just two pages, the JAMA article is reporting to all Americans that a paradigm shift in healthcare is underway. And as the author of the survey rather nicely concludes:
“The available evidence suggests that the next generation of physicians is ready to take part in this critical venture to define the future of medicine.”
David Edelberg, MD