The Affordable Care Act and Physicians: A Prescription for Change

In March 2010, the Patient Protection and Affordable Care Act was officially signed into law. As a result, in just a few short months, a projected 7 million previously uninsured people will become health plan consumers under the nation's existing fee-for-service reimbursement system. At the same time, the PPACA is introducing new care delivery and business models including the Pioneer accountable care organization and Medicare Shared Savings Program ACO pilots that incentivize providers for the value that they provide.

Nearly 250 government ACOs covering 4.1 million1 assigned beneficiaries, and more than 300 commercial ACOs covering another 14 million members2 are showing early signs of achieving what my professional colleagues have adopted (based on the work of Donald Berwick, MD): the triple aim plus one — reducing per capita healthcare cost, improving care quality and population health, and enhancing patient and physician satisfaction.

Despite the innovation spurred by the PPACA — and now the private sector — the overwhelming majority of patients remain under a volume-based model of healthcare reimbursement. With only 5 percent of physicians in value-based contracts, providers will be living in two worlds for the foreseeable future: the overwhelming majority focused on fee-for-service care and the small minority who are at the beginning stages of value-based care. In addition, because of the pressures and demands placed on physicians in the current healthcare environment, many are experiencing dissatisfaction, frustration and burnout in their current careers.

This article focuses on what can be done to help healthcare organizations achieve the triple aim plus one, with an emphasis on increasing physician satisfaction through the effective delivery of value-based care by providing them with the right tools, resources and clinically integrated, actionable information.

Problem 1: Physician concern, dissatisfaction and confusion
Before addressing the solutions, it's important to walk through some of the concerns. There is no doubt that the PPACA will impact how care is delivered and reimbursed. According to a survey by athenahealth, nearly one-third of physicians say they still don’t have a clear understanding of the details and implications of the law. Furthermore, 53 percent see the PPACA as detrimental to the delivery of high-quality care.3

Complicating matters further is the high dissatisfaction rate in the healthcare profession. When Jackson Healthcare (the third-largest healthcare staffing company in the U.S.) surveyed 3,456 physicians, 42 percent said they are dissatisfied with their career, and 59 percent said they would not recommend the medical profession.4 Many physicians feel they are running on a continuous hamster wheel, seeing four patients per hour with increasing administrative hassle and decreasing reimbursement. They have excessive work burdens with long hours and little time to effectively manage their patients' health.

With confusion surrounding the PPACA and the frightening lack of career satisfaction, there should be an exploration of potential outcomes of the law and what steps physicians and medical organizations can take to be successful in today's rapidly changing environment. Some additional key challenges under the PPACA include:

•    Having enough physicians to handle the influx of new patients
•    Acclimating patients who have been out of the healthcare system for years
•    Preventing physician burnout

Problem 2: Key challenges with a previously uninsured population
A key reason for uncertainty is that the previously uninsured individuals entering the marketplace could potentially have untreated or undiagnosed medical conditions that are expensive to diagnose and treat. They may also be unfamiliar with how to navigate a new health insurance industry, needing guidance on how to find a primary physician and when to schedule an appropriate appointment rather than seek treatment in an emergency room.

Because of the mandates of the PPACA, the previously unmanaged patients could, if not treated in the right care model, add to the level of physician dissatisfaction and cause more to leave the profession, increasing the shortage in the United States. Currently, about 20 percent of Americans live in an area that is experiencing a primary care shortage.5 Industry experts have predicted that the shortage of providers will grow to about 60,000 in a decade.

Problem 3: Struggles with data analytics
According to a recent study from the Annals of Internal Medicine,6 1,820 primary care physicians and specialists reported that they often struggled using their electronic health record systems for population management tasks. Details from the study included:

•    41 percent reported that they often struggled using the EHR systems for population management tasks
•    41 percent couldn't generate quality metrics using the EHRs
•    36 percent couldn't provide patients with after-visit summaries
•    42 percent couldn't exchange EHR information outside their practice

Medical organizations need new information, tools and engagement methods to coordinate their patients' care and manage their populations. This includes access to claims, lab, pharmacy and EMR encounter data, as well as tools that engage physicians and make the best use of information for better quality and cost outcomes. It is critical that physicians and medical personnel have full visibility across the continuum of care to ensure that they have the data they need to make actionable decisions at the point of care. Despite the push to adopt electronic health records, much clinical data is still fragmented and not easily shared among various systems.

Solution 1: A new care delivery model
Concerns about the new health insurance marketplaces are real, but new care models are showing great promise in improving the health of populations, physician satisfaction and reducing per-capita costs.

One of the models supported by the PPACA and ripe with opportunity is the accountable care organization model. ACOs are operated on a value-based model and break away from traditional fee-for-service. Essentially, physicians are given incentives to provide better and more efficient care by third-party payers. For example, CMS' MSSP program gives ACOs the opportunity to share in savings if they meet certain quality and cost benchmarks. By taking responsibility for the care delivered to patients, there is a potential in sharing a significant savings with CMS, financially rewarding physicians for meeting or exceeding the set benchmarks.

CMS also created the Pioneer ACO program that works directly with payers to align payer and physician incentives for improved cost and quality outcomes. Though this also comes with a shared savings component, there is greater risk involved, but also much greater reward. Like the MSSP plan, there is a shared savings component with CMS, and if cost and quality metrics are met, the reward is a greater percentage of the savings. Conversely, if cost and quality metrics are not met, there is shared loss as well.

With the right tools, such as a web-based platform that integrates data and provides actionable clinical information, these accountable and value-based plans are potentially quite profitable, even with the influx of patients. The right internet-based platform and applications can increase patient engagement, and help providers educate their patients, especially those who are visiting for the first time in many years. Materials and tools made available through such a platform can help patients remain at the center of their physician's attention, increase their compliance and close gaps in care, thus allowing the physician a better chance at receiving a share of the increased savings.

In addition, this model enables physicians to examine opportunities to reduce costs for their practice and their patients while maintaining high clinical quality. For example, the reduction of unnecessary services and appropriate use of specialty care, screenings and diagnostic tests all help maintain cost effectiveness. Also, the right tools, references and coding resources can reduce the number of hospital readmissions, which is an important focus of reducing the costs of care. From the physician's perspective, as these changes occur, career satisfaction becomes top of mind, and leads to the second solution that focuses on increasing physician satisfaction by helping him or her to thrive in this new world of accountable care.

Solution 2: Increasing physician satisfaction by helping them thrive
The challenges facing physicians are not insurmountable and can be broken down to demonstrate how the right solutions can lead to increased satisfaction.

First, an important strategy to increase satisfaction is through capacity expansion, which involves re-envisioning the traditional healthcare model through the use of information technology and re-architecting care delivery to include team-based care. Medical practices should set up procedures and policies with the goal of each member of the care team practicing to the highest level of his or her license. This model includes giving members of the care team the right information, through the right platform and applications, based on their given role and eliminating the burden from the physician.

Second is the ability for physicians to embrace and adopt the right technology for the right purpose. For example, PCPs and other members of the care team should utilize effective forms of communication with patients, such as email. Physicians should also invest more time in providing non face-to-face touch points with patients such as through e-visits, websites and applications available through mobile devices. (However, under the current reimbursement models, physicians may not be paid for time invested in non-facing patient engagements. To encourage such behaviors, reimbursement for non-traditional care should be addressed.)

Third, team-based care means different, role-based expectations for various staff members, greater responsibility at the appropriate levels, and more coordination and communication among the team members. Before jumping into new models of care, physicians should invest in continuing education opportunities for their care team, focusing on leadership skills and team management.

Finally, improving physician satisfaction requires efforts from payers and hospitals, as well as physicians and physician organizations. These efforts should focus on a few additional goals such as structuring work environments to simplify procedures and workflows while preserving control, emphasizing autonomy and requiring order within the practice environment. Another goal is to align incentives around value by providing the medical organizations with new information, tools and engagement tied directly to claims, lab, pharmacy and EMR encounter data, thus allowing them to make the best use of information for better quality and cost outcomes.

Ultimately value-based healthcare seeks to improve population health while increasing patient and physician satisfaction. The journey to such a model requires work, including planning how care is delivered, engaging physicians in assessing healthcare models and incentives, and creating the right web-based platform that provides medical professionals access to the clinically integrated data necessary to achieve a complete view of their patients.

Though the full impact of the PPACA is still unknown, what is known is that new care models are developing as a result of the changes, and cutting-edge healthcare organizations are finding ways to improve care, quality and satisfaction. With the right model, tools and incentives, physicians should not only survive the transition to value-based care, but thrive in this new environment. In fact, they will recharge the culture of care to center around meaning and significance in their work, support from their care team and a solid work-life balance.


Tom Doerr, MD, is a primary care physician practicing geriatric medicine in St. Louis and the vice president of clinical strategy for an IPA. He is a co-founder of Lumeris and the company's director of innovation research. In addition, Dr. Doerr serves on the board of directors for Essence Healthcare, and is a faculty member of the Accountable Delivery System Institute.

1 Centers for Medicare & Medicaid Savings,
2 Oliver Wyman, “ The ACO Surprise,” page 2, 2013
3 Athenahealth/Sermo Annual Physician Sentiment Index™ (PSI) Reveals Major Distractions from Patient Care, June 2012, Biomedical Market Newsletter;6/18/2012, Vol. 21, p1
4 Filling the void: 2013 Physician Outlook & Practice Trends, 2013
5 “Across US, localities are scrambling to ease shortage of primary-care physicians,” Associated Press, June 23.
6 Catherine M. DesRoches, Anne-Marie Audet, Michael Painter, Karen Donelan; Meeting Meaningful Use Criteria and Managing Patient Populations A National Survey of Practicing Physicians. Annals of Internal Medicine. 2013 Jun;158(11):791-799.

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