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More Obamacare-led Changes on the Front Lines


Continuing off her last blog, a physician shares more changes she has seen related to Obamacare on the front lines of medicine.

This blog is a continuation of my last installment and focuses on changes I’ve observed related to Obamacare. Last time, I discussed the challenges of high deductibles and co-pays on where patients choose to receive care, the expectation that we provide patients with excellent customer service, and the challenges of disconnected care teams. This blog will focus on additional changes that have occurred as the Affordable Care Act has been rolled out and continues the top six list of changes related to Obamacare.

4. Pay-for-performance remains incompletely understood and immature. Reimbursement tied to performance reporting and quality metrics predates the ACA, but has become more robust under the legislation. The challenges are myriad, and in areas such as rural health, pediatrics, and some specialty care, what and how to measure is still poorly defined. As a result, most healthcare systems are tasked with tracking performance on multiple measures (with different definitions of success) from different insurers and CMS. It is impossible to focus on everything and difficult to determine priorities. Additionally, the data showing a clear benefit to reimbursing physicians for quality performance is lacking. When benefit is realized, it may reflect only small improvement in very specific areas.

5. Payment reform is coming, right? There are token efforts in most markets and more sweeping efforts on the part of CMS to pay for value instead of quantity. We are several years into payment reform. However, I am still doing what my own primary-care physician did when I was growing up. I see patients face-to-face in clinic. That is how I generate revenue and how I provide care. Granted, I can also tell you the percentage of my patients who have controlled diabetes or who received their immunizations. There is heavy emphasis on providing quality care (the definition of which is open to debate - see above). However, the reimbursement for “quality” is not sufficient to generate interest across the entire healthcare spectrum to work together to reduce patient complications. I do not believe that any physician would provide poor care with the hope of making more money off a patient with complications, but given that teams of coordinated professionals are needed to make significant change in complex patients, the amount of money on the table is inadequate.

6. The EHR. I am a fan of the EHR - I would rather use it than go back to paper charting for many reasons. To the extent that the ACA has encouraged EHR use and provided incentives for implementation – Hurrah!  To the extent that the ACA and CMS have required hoop-jumping and clinically meaningless documentation – Boo!  The current state of EHRs in our country is lacking - they remain un-integrated, few are user-friendly, and they add rather than subtract hours of work each week. The ACA had a tremendous opportunity to innovate and integrate electronic medical record use but has failed to do so.

After reading all of this, you may believe that I have specific political leanings regarding healthcare reform. I do to the extent that I cannot support a politician who simply talks about doing away with the ACA without proposing a specific change that will improve the healthcare system. Moreover, despite all the pain points, I do feel that the ACA has pushed us further down the road to reform. As with any reform, there are mistakes made, lessons learned, and opportunities identified. Here’s hoping our next President and congress are courageous enough to build on the successes of the ACA (of which there are many) and to address the deficiencies.

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