Specialty, Political Affiliation, and Perceived Social Responsibility Are Associated with U.S. Physician Reactions to Health Care Reform Legislation

ABSTRACT

BACKGROUND

Little is known about how U.S. physicians’ political affiliations, specialties, or sense of social responsibility relate to their reactions to health care reform legislation.

OBJECTIVE

To assess U.S. physicians’ impressions about the direction of U.S. health care under the Affordable Care Act (ACA), whether that legislation will make reimbursement more or less fair, and examine how those judgments relate to political affiliation and perceived social responsibility.

DESIGN

A cross-sectional, mailed, self-reported survey.

PARTICIPANTS

Simple random sample of 3,897 U.S. physicians.

MAIN MEASURES

Views on the ACA in general, reimbursement under the ACA in particular, and perceived social responsibility.

KEY RESULTS

Among 2,556 physicians who responded (RR2: 65 %), approximately two out of five (41 %) believed that the ACA will turn U.S. health care in the right direction and make physician reimbursement less fair (44 %). Seventy-two percent of physicians endorsed a general professional obligation to address societal health policy issues, 65 % agreed that every physician is professionally obligated to care for the uninsured or underinsured, and half (55 %) were willing to accept limits on coverage for expensive drugs and procedures for the sake of expanding access to basic health care. In multivariable analyses, liberals and independents were both substantially more likely to endorse the ACA (OR 33.0 [95 % CI, 23.6–46.2]; OR 5.0 [95 % CI, 3.7–6.8], respectively), as were physicians reporting a salary (OR 1.7 [95 % CI, 1.2–2.5]) or salary plus bonus (OR 1.4 [95 % CI, 1.1–1.9) compensation type. In the same multivariate models, those who agreed that addressing societal health policy issues are within the scope of their professional obligations (OR 1.5 [95 % CI, 1.0–2.0]), who believe physicians are professionally obligated to care for the uninsured / under-insured (OR 1.7 [95 % CI, 1.3–2.4]), and who agreed with limiting coverage for expensive drugs and procedures to expand insurance coverage (OR 2.3 [95 % CI, 1.8–3.0]), were all significantly more likely to endorse the ACA. Surgeons and procedural specialists were less likely to endorse it (OR 0.5 [95 % CI, 0.4–0.7], OR 0.6 [95 % CI, 0.5–0.9], respectively).

CONCLUSIONS

Significant subsets of U.S. physicians express concerns about the direction of U.S. health care under recent health care reform legislation. Those opinions appear intertwined with political affiliation, type of medical specialty, as well as perceived social responsibility.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2523-0) contains supplementary material, which is available to authorized users.

INTRODUCTION

Recently, the U.S. Supreme Court upheld the constitutionality of the landmark U.S. health care reform legislation—the Patient Protection and Affordable Care Act (ACA). Reactions to the ACA and the Court decision have been mixed.^1,2 Currently, 47 % of the U.S. population approves of the law, while 43 % disapproves,³ with views falling largely along party lines.

What about U.S. physicians? President Obama introduced his health reform plan at the 2009 annual meeting of the American Medical Association (AMA), a choice reflecting the importance of physician leadership in U.S. health care and health policy. Previous research shows that the majority (78 %) of U.S. physicians agree that, in general, they have a professional obligation to address societal health policy issues⁴ and to be active politically (92 %), and at least one quarter (25 %) of physicians are politically involved at the local, state, and national levels.⁵ Physician enthusiasm for reform legislation may hinge on a broad range of concerns, including the perceived impact on time spent with patients, work hours, as well as perceived fairness of compensation for their work.

Now, with the ACA in full implementation, the U.S. Congress faces other challenges related particularly to physician reimbursement as an ongoing challenge in the publicly-financed Medicare system. For the last several years, legislated cuts to physician reimbursement under Medicare have been avoided only by last-minute legislated 1-year fixes. But with a pending budgetary crisis and political gridlock in Washington, that temporary strategy may not continue. Little is known about how physicians’ political affiliations, their specialty, their sense of social responsibility, or other characteristics relate to their reactions to health care reform legislation in general and reimbursement in particular.

The purpose of this study was to describe physicians’ views about the direction the ACA might take U.S. health care, their perception of the fairness of reimbursement under the ACA, trends in their perceived social responsibility since the ACA was passed, and to determine which physician characteristics, including self-described political affiliation, specialty, and perceived social responsibility, are associated with those judgments.

METHODS

This study was approved by the Mayo Clinic Institutional Review Board. In the summer of 2012, we mailed an eight-page paper survey entitled “Physicians, Health Care Costs, and Society” to a random sample of 3,897 U.S. physicians drawn from the AMA Masterfile. The AMA Masterfile includes nearly all doctors in the U.S. We included a self-addressed, stamped envelope for returns, sent the first two waves by Federal Express and Priority Mail, respectively, and a final mailing by first class mail. We included a $20 cash incentive in the first mailing with interval reminder/thank you cards. Part of the survey assessed opinions about the direction of U.S. health care under the ACA, including its impact on the overall direction of U.S. health care and its perceived impact on the fairness of physician reimbursement.

Survey Instrument Development

Through an iterative process of literature review, conducting focus groups with physicians and theme extraction from those focus groups, question formulation, cognitive interviewing with physicians, and question revision, we adapted and developed survey questions about physicians’ perspectives on health care reform, societal responsibilities, medical decision-making, and cost of health care. This report focuses on measures pertaining to the ACA.

Dependent Measures

We asked physicians to indicate their level of agreement with the following statement: “The Affordable Care Act, if fully implemented, would turn United States health care in the right direction.” Response categories were “strongly disagree”, “somewhat disagree”, “somewhat agree”, and “strongly agree”. Participants were then asked to respond to the following prompt: “The Affordable Care Act, if fully implemented, would make physician reimbursement…” Response categories included “more fair”, “less fair”, “neither more nor less fair,” and “not sure.” This second item was adapted from a previous survey that asked, “The impact of the Health Care Reform Act of 2010 will result in physician reimbursement becoming” with the same response categories.⁶

Independent Measures

To determine how those opinions related to physicians’ general beliefs about their societal responsibility, we asked three items previously measured in 2009 that bear directly on their scope of professional obligations⁴ (“Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligations as a physician”; “Every physician is professionally obligated to care for the uninsured and underinsured”; and “I would favor limiting coverage for expensive drugs and procedures if that would help expand access to basic health care for those currently lacking such care”).

We also measured key predictors including physicians’ political self-characterization (“How would you characterize yourself politically most of the time?” with response categories of “very conservative”, “somewhat conservative”, “independent/moderate”, “somewhat liberal/progressive”, “very liberal/progressive”, or “other”), demographic characteristics including age, sex, race, region (Midwest, Northeast, South, West), and their clinical specialty (subsequently categorized as primary care, surgery, procedural specialty, nonprocedural specialty, nonclinical specialty, and other. The complete classification of all specialties into these six categories is included in Appendix A (available online).

Analysis

We used descriptive statistics and logistic regression in SAS 9.2 (Cary, NC) to assess associations between physician characteristics and their judgments about the ACA running separate multivariate logistic regression models, with “direction of U.S. health care” and “fairness of reimbursement” as our respective dependent variables and age, sex, race, region, specialty type, perceived societal responsibility, practice compensation type, and self-described political affiliation as the independent variables. Model results presented in tabular form include only those variables with statistically significant (i.e. p < 0.05) findings.

RESULTS

Physician respondents were primarily male (70 %), age 50 or older (58 %), and white (77 %) (Table 1). Respondents and non-respondents differed somewhat by age [50 years and older: 58 %; less than 50 years: 54 % (Χ² = 5.4; p = 0.02)], but not by sex, region, specialty, or practice type. We confirmed that only age ≥ 50 (and not other characteristics) was associated with a greater likelihood of responding using multivariate logistic regression.

Table 1.

Characteristics of 2,556 U.S. Physician Survey Respondents

Characteristic	No. (%)
Male sex	1,784 (70)
Age (years)
Less than 50	1,079 (42)
50 or older	1,477 (58)
Race or ethnic group*
White or Caucasian	1,958 (77)
Asian	369 (15)
Other	124 (5)
Black or African-American	80 (3)
Region†
South	829 (33)
Midwest	594 (23)
Northeast	548 (22)
West	570 (22)
Primary specialty
Primary care	1,034 (40)
Surgery	571 (22)
Procedural specialty	486 (19)
Nonprocedural specialty	399 (16)
Non-clinical	44 (2)
Other	22 (1)
Practice compensation type‡
Billing only	1,036 (41)
Salary plus bonus	874 (35)
Salary only	460 (18)
Other	154 (6)
Political self-characterization§
Very conservative	254 (10)
Somewhat conservative	709 (28)
Independent/moderate	726 (29)
Somewhat liberal/progressive	495 (20)
Very liberal/progressive	247 (10)
Other	66 (3)
Registered to vote∥	2,394 (94)

Response rates differed slightly by age (50 years and older: 67 %; less than 50 years: 64 %; chi-square p value = 0.02) but not by sex, region, or specialty

^*Percentages based on a denominator of 2,532

^†Percentages based on a denominator of 2,541

^‡Percentages based on a denominator of 2,524

^§Percentages based on a denominator of 2497

^∥Percentage based on a denominator of 2,535

Among the 2,556 physicians who responded (RR2: 65 %),⁷ two out of five (41 %) believe that the recent U.S. health care reform legislation will turn U.S. health care in the right direction (Table 2). Only 7 % of surveyed physicians believe that the law will make physician reimbursement more fair, while 44 % believe it will make physician reimbursement less fair (Table 2). Physician respondents were split in self-reported political affiliation (38 % conservative, 29 % independent, 30 % liberal); nearly all respondents (94 %) indicated they are currently registered to vote, and just over half (53 %) described their practice’s primary compensation structure as salary or salary plus bonus (Table 1).

Table 2.

U.S. Physician Respondents’ Opinions About the Affordable Care Act

	No. (%)
	Strongly disagree	Moderately disagree	Moderately agree	Strongly agree
The Affordable Care Act, if fully implemented, would turn United States health care in the right direction.	743 (31)	651 (27)	693 (29)	298 (12)
	Not sure	Less fair	Neither more nor less fair	More fair
The Affordable Care Act, if fully implemented, would make physician reimbursement…	720 (30)	1,067 (44)	462 (19)	159 (7)

About two-thirds of respondents agreed that every physician is professionally obligated to care for the uninsured or underinsured (65 %). Half (55 %) were willing to accept limits on coverage for expensive drugs and procedures for the sake of expanding access to basic health care.

Compared to political conservatives, self-identified liberals and independents were both substantially more likely to endorse the ACA (OR 33.0 [95 % CI, 23.6–46.2]; OR 5.0 [95 % CI, 3.7–6.8], respectively) and to believe it will make physician reimbursement more fair (OR 8.8 [95 % CI, 4.5–17.5]; OR 4.5 [95 % CI, 2.2–9.1]; respectively), after adjusting for age, sex, race, region, specialty, practice compensation type, and responses to the three items related to societal responsibility.

Medical specialty was also strongly associated with physicians’ views about the ACA. Surgeons and procedural specialists were significantly less likely than primary care providers to agree that the ACA will benefit U.S. health care (OR 0.5 [95 % CI, 0.4–0.7], OR 0.6 [95 % CI, 0.5–0.9], respectively), and were significantly less likely to believe that the ACA will render physician reimbursement more fair (OR 0.2 [95 % CI, 0.1–0.5], OR 0.5 [95 % CI, 0.3–0.9], respectively) (Table 3). In the same multivariate models, physicians who were salaried were significantly more likely than those with a billing-only compensation structure to agree that the ACA would turn U.S. health care in the right direction (ORs 1.7 & 1.4 [95 % CIs 1.2–2.5 & 1.1–1.9] for salary only and salary plus bonus, respectively). Salary type was not associated with views about the fairness of compensation under the ACA.

Table 3.

Associations Between Opinions About the ACA and U.S. Physician Characteristics

	OR (95 % CI)
	Agree the ACA would turn U.S. health care in right direction	The ACA would make physician reimbursement more fair
Primary specialty
Primary care	1.0	1.0
Surgery	0.5 (0.4–0.7)*	0.2 (0.1–0.5)*
Procedural specialty	0.6 (0.5–0.9)*	0.5 (0.3–0.9)*
Nonprocedural specialty	0.8 (0.6–1.2)	0.6 (0.4–1.1)
Non-clinical	0.9 (0.4–2.1)	0.9 (0.3–2.6)
Political self-characterization
Very or somewhat   conservative	1.0	1.0
Independent/moderate	5.0 (3.7–6.8)*	4.5 (2.2–9.1)*
Very or somewhat   liberal/progressive	33.0 (23.6–46.2)*	8.8 (4.5–17.5)*
Practice compensation type
Billing only	1.0	1.0
Salary only	1.7 (1.2–2.5)*	1.1 (0.7–1.9)
Salary plus bonus	1.4 (1.1–1.9)*	1.4 (0.9–2.1)
Other	1.0 (0.6–1.7)	0.9 (0.4–2.1)
Societal responsibility
Addressing societal health     policy issues falls in scope     of professional obligations
Strongly/moderately       disagree	1.0	1.0
Strongly/moderately       agree	1.5* (1.0–2.0)	1.2 (0.7–2.2)
Every physician has     responsibility to care for     un/underinsured
Strongly/moderately       disagree	1.0	1.0
Strongly/moderately       agree	1.7* (1.3–2.4)	1.0 (0.6–1.7)
Favor limiting coverage     to expand access to care
Strongly/moderately       disagree	1.0	1.0
Strongly/moderately       agree	2.3* (1.8–3.0)	3.2* (2.0–5.3)

Odds ratios presented here from multivariate logistic regression models including only those variables with significant findings. Other variables included in models were age, sex, race, and region

*Wald p value  < 0.05

Physicians’ beliefs about each of the three surveyed categories of social responsibility were related to their support for the ACA. Physicians who believe addressing societal health policy issues are within the scope of their professional obligations (OR 1.5 [95 % CI, 1.0–2.0]), who believe physicians are professionally obligated to care for the uninsured / under-insured (OR 1.7 [95 % CI, 1.3–2.4]), and who agreed with limiting coverage for expensive drugs and procedures to expand insurance coverage (OR 2.3 [95 % CI, 1.8–3.0]), were all significantly more likely to endorse the ACA. Those who favored limiting coverage for expensive drugs and procedures were over three times as likely to believe the ACA would make physician reimbursement more fair (OR 3.2 [95 % CI, 2.0–5.3]).

DISCUSSION

U.S. physician opinion about landmark health care reform legislation demonstrates unease about the law within large sectors of the profession. U.S. physicians’ political affiliation, a factor not previously well studied in the academic literature, and specialty type both appear to be significant factors in their impressions about the direction of U.S. health care under the ACA. Moreover, while most physicians express a strong and broad sense of social responsibility, those sentiments were even stronger among supporters of health care reform legislation.

Beyond political affiliation, our data suggest that unease about the direction of U.S. health care under the ACA is disproportionately concentrated among surgeons and procedural specialists. Primary care physicians may disproportionately see provisions from the ACA, such as enhanced coordination of care, electronic health records, and bundled payment systems as having a positive influence on their practice and reimbursement. In contrast, surgeons and procedural specialists who preferentially benefit financially from existing fee-for-service payment models may view those same innovations as potential threats to the way they are used to making a living. Whether this majority unfavorable reaction to the ACA by U.S. physicians will fade once the law is fully implemented is unclear. Some national physician polls conducted in 2011 suggested similar negative reactions within the profession with especially negative reactions to fairness of reimbursement among surgeons.⁶ Our findings with a more representative sample and more detailed methodology reveal a relatively lesser degree of pessimism in 2012.

Moreover, whether these reactions represent informed opinions of physicians or gut reactions toward the ACA is less clear. To our knowledge, there are no published surveys since the passage of the ACA that have assessed practicing physicians’ knowledge of the legislation. Among medical trainees, Winkelman et al. found that less than half of medical students surveyed reported understanding the basic components of the ACA.⁸ Huntoon et al., in a national survey of ten medical schools, concluded “The overwhelming majority of medical students recognized healthcare reform is needed and expressed support for the PPACA but echoed concerns about whether it will address issues of quality or cost containment.”⁹ To our knowledge, no published systematic physician surveys since the passage of the ACA have examined practicing physicians’ actual knowledge of the ACA. Furthermore, medical educators must address the insufficiencies in policy education if they wish future providers to be active in health reform. Future work assessing physicians’ experiences with and support for key practice-changing provisions in the legislation in the early phases of its implementation may be more crucial to its success or failure to improve care. As 2014 initial ACA implementation initiatives unfold, gauging physician reactions will be important to understand their comfort with reforms that will be appearing in the coming years.

Addressing physicians’ concerns about the direction of health care under the ACA particularly among conservatives (one third of all U.S. doctors), surgeons, and other procedural specialists may require engaging more widely shared moral sensibilities of these physicians, since professional opinion overall still strongly favors physicians’ involvement in health care policy and social responsibility. As the ACA is implemented in the coming years, proactive communication from the Department of Health and Human Services about the potential positive impact of the ACA on U.S. physician job satisfaction, protection of time with patients, and transparency about its potential impact on compensation and reimbursement may allay the apparent reservations in these groups.

These cross-sectional data cannot establish causal relationships between any of the variables assessed in this analysis. We also did not ask for in-depth opinions about specific components of the ACA. Instead, we asked physicians whether they agreed or disagreed with the direction of U.S. health care under the ACA. Whether physicians agree with specific components of the ACA despite a visceral reaction against the law as a whole remains unclear. Although novel, the outcome measures reported here have not been extensively validated by multiple investigators in multiple samples over time.

Notwithstanding these limitations, this study represents the first systematic report of physician political characterization and how those characterizations relate to a landmark health policy issue in the U.S. Although U.S. professional medical organizations have supported the ACA, significant subsets of physicians remain skeptical that the ACA will turn U.S. health care in the right direction—sentiments that appear intertwined with political affiliation and type of medical specialty.