With the demise of Republican repeal and replace legislation, analysts say the landscape is ripe for repairs to the Affordable Care Act or for additional legislation that both political parties could support. So what do physicians want from health reform?

The first step should be stabilizing the health insurance marketplaces by strengthening and perhaps extending risk mitigation measures such as the risk adjustment, risk corridors, and reinsurance provisions of the law, said Patricia Salber, MD, an internist and health care consultant who blogs at TheDoctorWeighsIn.com. Those three ACA provisions were intended to promote insurer competition on the basis of quality and value and promote insurance market stability.

“Stabilization of the marketplaces would benefit physicians as well as patients, providers, and plans, ensuring payment for services instead of returning to the bad old days of cost-shifting to pay for [uninsured] and underinsured,” Dr. Salber said in an interview.

Keeping premiums at manageable levels for patients should also be addressed, said William J. Burke , DO, dean of Ohio University Heritage College of Osteopathic Medicine.

“Without a doubt increased premium costs and high deductibles for patients insured through the system have become a challenge,” Dr. Burke said in an interview. “I do think we need to reign in to the best of our ability, those increase in premium costs. To be fair, in many markets, we have seen some stabilization, but in other markets, we have seen substantial increases.”

That was echoed in a poll taken by this news organization. Of 390 respondents, fully half (50%) said they would repair the ACA by stabilizing premiums and out-of-pocket costs for patients as of April 2. About 11% stated they would increase payment rates for care provided to Medicaid patients, and 10% said they would return the primary care incentive payment. About 9% of those surveyed would address workforce issues exacerbated by more patients in the system.

Other priorities cited by respondents ranged from allowing insurers to compete across state lines to tighter regulation of drug prices to permitting balance billing by physicians. Some respondents expressed the need for a complete repeal and replace of the ACA, while others said health care needs to move to a single payer system. Changing the ACA’s individual mandate was frequently recommended, with some respondents wanting the mandate eliminated and others suggesting that the cost of noncompliance with the mandate be increased and the mandate itself better enforced.

Improving reimbursement for Medicaid services is a necessary health reform change, agreed Diane J. Horvath-Cosper MD, an obstetrician-gynecologist and reproductive health advocacy fellow for Physicians for Reproductive Health, a reproductive rights advocacy organization.

“Reimbursement rates are so low that sometimes [physicians] have to limit the number of Medicaid patients to be able to pay staff,” Dr. Horvath said in an interview. “That’s a terrible position to put physicians in because we want to be able to see as many people who want to see us.”

Speaking of Medicaid, Dr. Salber adds that governors should be encouraged to continue expanding Medicaid to eliminate the coverage gap for the “near poor” that exists in states that did not participate in the expansion.

“Now that the [American Health Care Act] has failed, I think we will see some expansion take place organically even in states that were deeply opposed before,” she said.

Reducing the administrative burden of prior authorizations should be considered a top health reform priority, added Michael L. Munger , MD, president-elect of the American Academy of Family Physicians. He said the AAFP would like to see all plans – public and private – use a standard form and standard process for all prior authorizations. In addition, the need for prior authorizations should be examined and eliminated in some areas, such as for generic medications for Medicare patients or for patients with chronic disease who are on an established treatment regimen.

“The volume of prior authorizations that all physicians face, but especially primary care physicians, is huge,” Dr. Munger said in an interview. “In many cases, we’re having to hire extra staff just to handle all of the prior authorizations. Every patient may not just have one prior authorization, but they may require two or three or four prior authorizations each month or quarterly. It really detracts from meaningful time you can spend with the patient.”

Meanwhile, Jane Orient , MD, executive director for the conservative Association of American Physicians and Surgeons, said health reform efforts should include a complete revamping of how physicians are paid. The AAPS is opposed to the ACA and would like to see repeal and replace legislation enacted.

For starters, doctors should provide care to patients based on mutually agreed terms and without the interference of insurers, Dr. Orient said in an interview. In such a private medicine system, patients would pay doctors for services, and patients would then file claims with their insurer for reimbursement. Similarly, physicians should not be at the mercy of Medicare for payment, Dr. Orient said.

“Doctors can sign away their rights if they want in a Medicare participation agreement,” she said. “Doctors who do not sign the agreement to take assignment in all cases doctors should be freed of price controls and coding demands. Their patients should be allowed to file their own simple claims to Medicare with an itemized bill as they did before the 1990s law that requires physicians to submit the claims. Non-participating doctors should be exempted from MACRA [the Medicare Access and CHIP Reauthorization Act], and without the price controls, there is no need for [Recovery Audit Contractors] and other auditors.”

While contraceptive care was strengthened by the ACA, Dr. Horvath said further efforts should be made to improve coverage and level the playing field for reproductive medicine. In addition, she said that abortion should be treated a valid medical procedure, rather than parsed out, and both public and private insurers should be required to pay for the procedure, she said.

“I would love to see strengthened provisions for contraception coverage,” Dr. Horvath said. “[We need to] make sure that doesn’t get bargained away. The other thing is to expand coverage and make sure every method is covered, not just one method in each category.”

Addressing the opioid epidemic and achieving innovative medical liability reform are top issues that should be included in any new health reform legislation, Nitin Damle , MD, president of the American College of Physicians (ACP), said at a March 31 press conference. The ACP also supports reform legislation that builds on existing requirements that insurers and Medicare cover essential benefits, lowers deductibles, makes premiums more affordable, and preserves the existing federal commitment to Medicaid, while allowing for state innovation.

However, Robert Doherty , ACP senior vice president of governmental affairs and public policy, said the college is concerned that the current administration may fail to maintain the ACA now that its proposed repeal law has fallen through.

President Trump and the Congress have sent mixed messages about their next steps regarding health reform. Some Republican leaders have said they will go back to the drawing board to craft a new law, while President Trump has reportedly said he will wait for Democrats to approach him about making changes to the ACA.

Without aggressively pushing ACA enrollment for younger patients and continued support for the individual mandate, more insurers may pull out of the marketplaces, and the ACA could implode, Mr. Doherty said.

“There are a number of ways that Republicans could either make things better or worse with action or inaction,” Mr. Doherty said during the press conference. “The insurance [companies] have gone to this administration with a wish list of things that will help keep them in the market. What remains to be seen is whether this administration is going to be receptive. If they don’t aggressively enforce the requirement that people buy coverage, more younger people will opt out and stay out until they get sick. That would make the problem of adverse selection even worse and could create the death cycle for insurance.”

The White House remains committed to rolling back aspects of the ACA. Among the most prominent provisions in their crosshairs is the essential health benefits package that all plans must cover. During a March 29 House Appropriations subcommittee hearing, Tom Price , MD, Health and Human Services secretary, was asked repeatedly about whether he supported mandated coverage of specific portions of essential health benefits package, specifically contraception and mental health care services.

Dr. Price consistently answered that Americans should be able to select the kinds of coverage they want. What “we believe is that individuals ought to be able to have access to the kind of coverage that they select for themselves and for their families and not what the government forces them to buy,” Dr. Price testified, echoing the message from his confirmation hearings.

He was also pressed on issues such as the individual mandate, and while noting that it is his duty to uphold the law of the land, he also remained noncommittal in answering questions about whether he would direct the agency to enforce the individual mandate. The first executive order from President Trump beginning his administration gave the agency discretion to not enforce mandates if they caused harm.


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Gregory Twachtman contributed to this report.