About 50 years ago, songwriter Bob Dylan released “The Times They Are A-Changin’,” a piercing social commentary on the changes taking place during an especially turbulent time. He warned of the consequences of resisting change:
“If your time to you is worth savin’
Then you better start swimmin’ or you'll sink like a stone
For the times they are a-changin’”
I think the same could be said today about changes taking place in health care. From the Affordable Care Act (ACA)'s unprecedented expansion of health insurance coverage to the call for more transparency in health care pricing to the movement away from fee-for-service, the times surely are a-changin’ for American medicine.
Some physicians are inclined to resist change. My view is that defending a status quo that denies affordable coverage to tens of millions and costs far too much is unwise. I believe that physicians must be part of the change, that is, must “swim” with the tide of change coming to payment and delivery systems. They need to become more informed about the ACA by helping their patients benefit from the health exchanges, subsidies, Medicaid expansion and insurance consumer protection standards created by the law.
This does not mean blindly going along with changes that could do harm: Physicians should embrace changes to improve the quality and availability of health care, even as they are obligated to speak out against changes that do the opposite.
Physicians will need help in preparing for change, for example, through advocacy to ensure that Congress provides enough time and stability in Medicare payments for physicians to successfully engage in the new delivery and payment models that will largely replace stand-alone fee-for-service reimbursement.
This advocacy should ensure that physicians have a variety of such models to choose from (rather than having a “one-size-fits-all” payment system imposed on them that may not work well for their practice, their specialty, and their patients) and should ensure that the ACA lives up to its promise of providing patients with more options for affordable coverage, unaccompanied by disruptions that could harm patient care. Physicians also need help in the form of tools, resources and practical advice and assistance to help them make the necessary changes in their own practices.
The American College of Physicians is providing such advocacy and resources. In testimony presented in May to a congressional committee hearing on reform of the Medicare physician payment system and repeal of the sustainable growth rate (SGR) formula, the College proposed reforms to repeal the SGR, provide positive annual payment updates to all physicians, and allow for a transitional period of at least five years for physicians to participate in new value-based payment models. The College also proposed that physicians who are ready now to begin adopting “best practices” aligned with value be supported with additional positive, quality-based incentive updates during the transition.
The College noted in its testimony, “Such a transition must recognize that physicians are starting out in different places on incorporating best practices to achieve greater value for their patients, with some physicians already being very far down the road in redesigning their practices to achieve better value, while others are just getting started on the entrance ramp to value-based payments and delivery models.”
Since then, ACP has provided ongoing input on draft SGR repeal legislation with the goal of ensuring that it provides the necessary stability and support to physicians making the transition to value-based models.
The College similarly provided detailed recommendations to the Senate Finance Committee, which is drafting its own SGR repeal bill, on how to improve the existing Medicare fee-for-service system, reduce overutilization, and help physicians move into value-based payment and delivery models. Sen. Max Baucus, chair of the Senate Finance Committee, singled out ACP's letter for praise in opening remarks he made at the hearing on Medicare physician payment reform:
“I want to highlight the letter from the American College of Physicians. They gave us concrete examples, down to how Medicare could incentivize physicians to use guidelines that help them decide when to order tests and perform procedures. This would encourage doctors to provide the care seniors need, and avoid unnecessary care that might cause harm. I'm not saying we will accept all of their suggestions, but their comments help us see different angles of potential policies.”
The College also remains very involved in advocacy relating to ACA implementation, having submitted comments on almost all of the major proposed rules that will determine which benefits will be offered, how people will enroll in the marketplaces (exchanges) in each state, how the subsidies to help people buy coverage will work, and which consumer protection standards will apply to all health plans, including those provided by large employers. The College and its chapters also continue to advocate for states to agree to accept federal dollars to expand Medicaid to all poor and near-poor residents.
Physicians also need tools that can help them anticipate and take timely steps to prepare for changes affecting their practices and professional lives. In June, the College launched its new Physician and Practice Timeline. This Web-based resource provides a helpful at-a-glance summary of upcoming important dates related to a variety of regulatory, payment, educational and delivery system changes and requirements, as well as resources to help physicians make changes in advance of key deadlines. The tool currently tracks ICD-10 coding, the Medicare quality reporting and e-prescribing incentive programs, the Sunshine Act, meaningful use standards for electronic health records, and transitional care management codes. More programs and resources will be added. The College also will be partnering with other organizations to make practical Web resources available to members on all aspects of the ACA, including FAQs to help physicians anticipate questions from their patients on how to find out if they are eligible to get subsidized coverage.
It is often noted that change isn't easy, but it is inevitable. I am confident that most physicians want to be part of the change of creating a health care system that covers more people and delivers care more effectively and efficiently, supported by the right mix of payment incentives.
No one wants to see physicians in practice sink like a stone, and it is the responsibility of advocacy organizations like ACP to help them swim with the changes taking place.