Politics and public policy has long had an impact on healthcare, which has only become more significant since the Patient Protection and Affordable Care Act was implemented. Many physicians and medical professionals have undergone significant changes to meet regulatory requirements and survive market place evolution.
The North American Spine Society, along with other professional medical organization and advocacy groups, have reached out to legislators to advocate for patient access to appropriate care, with mixed results.
"NASS has been very frustrated with working with Congress over the past six to eight years," says John Finkenberg, MD, an orthopedic surgeon at Alvarado/Helix Orthopedics and Sports Medicine in California and North American Spine Society Advocacy Chair. "We have not been able to get our agendas completed and had to drop several initiatives along the way for various political reasons."
The past two Congresses passed less than 60 bills over their terms, a historic low. Neither party was willing to work with the other, and some members of Congress vowed obstruction regardless of the legislation introduced. However, on Nov. 2, 2014, several new Congress members were elected to give both congressional houses a Republican majority.
"The gridlock in Washington is getting to an unbearable stage," says Dr. Finkenberg. "The recent election shows the dissatisfaction of the American people." The recent elections may have been more about voting out Democrats and the old regime rather than voting in the Republican candidate.
However, any legislative moves will have to happen quickly. The next six months is a critical time in Washington before Democrats and Republicans switch their focus to future elections.
"After six months, each political party will begin to go in line with what will result in a successful presidential candidate and election in 2016," says Dr. Finkenberg. "They'll be focused on the election for the 18 months following that. I do think people will make initial postures to push the healthcare issues forward during the next six months, but my concern is the Congress and Senate both want to show the public they are also able to attack other issues on top of the political agenda, like immigration, economy and job issues."
During that six months' time, the Republicans will want to show they can make the political system work under the current structure, but that will be difficult with the Presidential veto power. In all likelihood, healthcare reform will continue in its current state.
"I think the spine community has realized the ACA isn't going away," says Dr. Finkenberg. "The efforts now will be placed on how we can make the system work. All of our strengths and efforts need to be directed in that area to figure out the issues. At this time, our concerns about the administrative burden of reporting quality measures and administrative reviews are so important."
When Dr. Finkenberg goes to Washington, he mentions the patient-physician relationship degradation to lawmakers, and makes sure to tell them patients aren't happy. Patients appreciate the care provided, but they want to spend more time with their surgeons instead of the surgeons spending time entering their data.
NASS members also recently made changes to the advocacy committee, voting for the advocacy committee to become one of the five councils from NASS. In the 2014 midterm elections, 92 percent of the candidates the NASS PAC supported won their elections.
"The advocacy council will have better access to the executive committee, board of directors and CEO," says Dr. Finkenberg. "That represents a major thrust for the future where we put our energy and dollars. We're putting together a war chest for members of Congress who are willing to listen and work with us. Not everything has to go our way, but there are things we can do to help patient quality."
A few of the biggest issues facing spine surgeons — and the medical profession — over the next few years are:
1. Global payments. "We understand Congress is trying to decrease costs for surgical procedures with global payments, and that's one way to do it, but our concern is as healthcare changes the patients will have significant copay and deductible increases," says Dr. Finkenberg. "When patients have to pay a higher amount, they could delay care. Additionally, physicians are penalized if patients have bad outcomes. But human nature will sometimes lead to poor follow-up from the patients and punishing physicians for the patients' bad decisions."
For example, the patient might have surgery and schedule follow-up visits with their surgeons to detect potential complications early. But when patients feel fine, some of them might cancel the follow-up visits or decide not to follow the rehabilitation plans which lead to rehospitalizations, infections and complications that could have otherwise been prevented.
"Those issues wouldn't be covered if they fall within a certain amount of time after surgery, and that's on our dime," says Dr. Finkenberg. "We are trying to work with patients and legislators to find a solution that provides good quality care for patients and is cost-effective."
2. Physician shortages. Another other huge issue is the physician shortage. By 2020, the country is expected to have a 90,000 physician shortage; by 2025 the shortage is expected to grow to 130,000 physicians. Many people mistakenly think this shortage is among primary care physicians, but Dr. Finkenberg sees the shortage being about 50/50 between primary care physicians and specialists.
"With graduate medical education funding, hopefully we'll be able to turn this around," he says. "But that's not a turn-key solution. It takes time. The HHS secretary has an obligation to find a half-percent of savings every year, otherwise that will come off of the Medicare physician fee schedule. She is looking at some of the misvalued codes, but she still has to make cuts so we are concerned it's going to be difficult for her to determine whether payments are correct or not."
3. IPAB repeal. For the first few years after healthcare reform was passed, the Independent Payment Advisory Board was an easy target for healthcare professionals and legislators on both sides of the aisle to attack. IPAB is designed to make recommendations on Medicare coverage if spending goes up; for now, Medicare spending continues to go down.
"I don't think IPAB will likely convene in the future, and I don't think we'll see a repeal," says Dr. Finkenberg. "Medicare per capita costs are going down and the only way the group would be convened would be if that changed. I think since that has bipartisan support, it's pretty unlikely it will be anything more than a threat."
4. SGR change. Physician groups have been pushing sustainable growth rate repeal for years, with a big push last year. However, SGR remains as the calculating method for Medicare payments and Congress continues to create patches so rapid rate drops don't devastate physicians.
"I think the last few proposals that have been put through to give surgeons a feeling of where it's going over five to 10 years," says Dr. Finkenberg. "It's a matter of whether the topic is too hot of a political issue to deal with in this first six months; I think it probably will be. The SGR also has bipartisan support."
5. Tort reform. Healthcare reform legislation passed in 2010 did not address medical liability or tort reform. However, individual states such as California and Texas with medical liability reform show it can reduce waste and lower overall healthcare spending. Recently, California Proposition 46 challenged medical malpractice caps; the proposition was defeated after advocacy from the medical community, as well as others.
"That rule has been in place since the early '70s and it's made malpractice costs significantly lower in California than it would be otherwise," says Dr. Finkenberg. "When malpractice goes up, the cost of care goes up. This legislation has the support of physicians, hospitals and unions, and after seeing what happened in California I think other states are going to key-in on how well the tort reform is working."