The Patient Protection and Affordable Care Act (ACA), commonly referred to as “Obamacare,” was enacted in March 2010 and represents a significant change in United States health policy and health-care delivery. With goals of expanding coverage to the uninsured, as well as emphasizing improved quality, the ACA aims to curb health-care costs and improve patient outcomes.1
Many questionnaires have explored the knowledge and viewpoints of the general public, students, and physicians.2–6 A recent Bankrate.com survey addressed uninsured Americans, finding that 30% of surveyed Americans feel “more negative” about the ACA than they did one year prior.2 Deloitte found that in 2012 a third of Americans “felt positively” about health-care reform compared with 49% in 2011. A Jackson Healthcare survey of 2726 physicians (38 of whom were plastic surgeons) found that a mere 27% of respondents felt “very knowledgeable” of the ACA, and 53% of respondents believed that the ACA will negatively affect their practice.4 It remains unclear how plastic surgeons feel regarding the ACA. The primary goals of this study were to assess plastic surgeons’ knowledge of the ACA and evaluate how they believe the ACA will impact their practice and profession.
Using an online survey program (SurveyMonkey, Palo Alto, Calif.), a 35-question survey was electronically sent to members of the American Society of Plastic Surgeons (ASPS) as a joint endeavor between the ASPS and the University of Wisconsin–Madison. A link to the survey platform was embedded in an e-mail offering a brief description of the survey and its intent. The survey was anonymous and voluntary, and no compensation was offered.
The survey questions included an assessment of demographic information: sex, age, political self-identification, number of professional memberships, postgraduate training, practice type and location, and patient population. Respondents’ understanding and opinions of the ACA were assessed using 5-point Likert-scale questions. “Strong versus weak effect” statements were included to evaluate plastic surgeons’ perceptions of the ACA’s impact on personal practice, the specialty, and the health-care system. Respondents were also asked to give the ACA a letter grade. The final question asked participants to select a generalized statement with which they agreed most.
The survey was sent via e-mail by the ASPS on 3 separate occasions in May and June 2014. Responses were collected and de-identified using the SurveyMonkey program.
Data were analyzed using frequency calculations, for which confidence intervals were included. Chi-square tests were performed to evaluate the relationships between responses, and a P-value ≤ 0.05 was considered statistically significant. Statistical analysis was performed using SPSS software (SPSS, Chicago, Ill.).
The survey was sent to 3070 ASPS members, and the response rate was 17%. Of those who responded, 82% were men. Age was evenly distributed with 30% between ages 35 and 44, 27% between ages 45 and 54, and 29% between ages 55 and 64. Forty-one percent of surgeons self-identified as “conservative” and 7% as “very conservative” compared with 16% selecting “liberal.” Fifty percent of respondents are members of 1–3 professional organizations and 41% members of 4–6. When asked to select a practice type, 43% of surgeons selected that they are part of a “solo practice,” 21% a “small group practice” (2–5 plastic surgeons), and 15% in “academic” practice. These percentages were similar to practice types of all ASPS members (Table 1). Almost one third (30%) of respondents describe their practice composition as 75% reconstructive and 25% cosmetic. Please see Table 1 for further breakdown of demographics and practice details.
Self-perceived Knowledge of the ACA
The majority of respondents either agree (54%) or strongly agree (14%) that they understand the basic concepts of the ACA (Table 2). In addition, respondents agree (51%) and strongly agree (18%) that the ACA addresses reconstructive procedures (it does), whereas the majority disagree with the notion that the ACA addresses cosmetic procedures (it does not). With respect to the sustainable growth rate, 49% agree and 9% strongly agree that they understand its basic concept. The majority of surgeons (46%) agree or strongly agree (12%) that they understand the medical devices tax. Respondents seem to be less familiar with the concepts of the physician value-based payment modifier (31% disagree and 9% strongly disagree that they understand the basic concept) and independent payment advisory board (32% disagree, 13% strongly disagree).
Effect on Individual Practice and Plastic Surgery
Over one third of surgeons (38%) strongly disagree with the notion that the ACA will positively affect their practice (31% disagree, 19% undecided), and 30% strongly disagree that it will contribute to increased volume (Table 2). Similarly, 46% strongly disagree that the Act will promote innovation in plastic surgery. Interestingly, a mere 2% strongly agree and 21% agree that the ACA will increase insurance coverage of plastic and reconstructive consultations and procedures although 24% remain undecided. With respect to access, 19% agree that it will increase access to plastic and reconstructive surgeons (22% undecided, 29% disagree, and 27% strongly disagree).
Surveyed plastic surgeons were provided 5 distinct “agreement statements” and asked to select the statement with which they agreed most. Fifty-one percent of respondents selected the statement, “I do not support the ACA, and I believe it did too much”, whereas 13% selected, “I am neither ‘for’ nor ‘against’ the ACA.” Almost one-fourth, or 23%, selected, “I support the ACA, but I think it needs more work.” When asked to provide an overall letter grade to the ACA, 36% offered a grade of “F,” whereas 1% selected a grade of “A.”
Effect of the ACA
With respect to questions that assessed whether the ACA will have a strong or minimal effect on variables related to patients, physicians, and the health-care system, it was observed that for most of the questions, approximately one third of respondents selected “unknown” (Table 2). Forty-five percent of surgeons believe that the ACA will have a strong effect on cost to the health-care system; 37% feel that the ACA will have a strong effect on cost of services provided to patients. When asked about preoperative counseling and shared decision-making, 24% believe it will have a strong effect (compared to 25% minimal effect, 22% no effect, and 29% unknown effect).
Responses Separated by Demographics
Answers to “understanding” and “agreement” statements were analyzed between groups for certain demographics. For example, when responses to the final question, “Please select the statement with which you agree most,” were separated by practice type, it was found that responses from those who practice in an “academic” setting were significantly different from those who are part of a “solo practice.” Forty-two percent of surgeons who selected “academic” for practice type identify with the statement, “I support the ACA but I think it needs more work,” compared with 15% of those who selected “solo practice” (P < 0.001). In addition, 57% of respondents who selected “solo practice” opted for the statement, “I do not support the ACA and I believe it did too much,” compared with 22% of surgeons with “academic” practice background (P < 0.001).
The primary goals of the ACA are to increase the number of insured individuals in the United States, improve health-care quality, and control long-term costs by prioritizing disease prevention.1,7 One key feature of the ACA is the provision of coverage to the uninsured, which, coupled with the promotion of quality and standardization of care, will minimize patient morbidity and, in the long term, curb health-care spending. Kocher et al7 outline 10 elements of reform, which include increased emphasis on shared decision-making discussions and patient-centered outcomes research, both of which are relevant to plastic surgery. Many of the components of the ACA, however, are centered on primary care and the prevention of chronic medical conditions, which are less commonly addressed by plastic surgeons. Under the Act, surgical subspecialties will likely experience changes to the coverage of services and reimbursement that may be viewed as unfavorable when compared to the ways of years past.
Individual plastic surgeons and the specialty of plastic surgery will likely experience changes related to the ACA. An increase in Accountable Care Organizations, or groups of physicians who practice at a hospital, will likely contribute to the phasing-out of “fee-for-service” reimbursement.1 Despite expected changes, the overall impact of the ACA on plastic surgery may not be particularly drastic. At our academic institution, a small percentage of payments to our division come from Medicare and Medicaid; as such, significant changes to government reimbursement will likely have a minimal overall impact on plastic and reconstructive procedures and consultations.1 Further, there may be some positive changes for plastic surgeons, as physicians may be rewarded for focusing on patient-reported outcomes including overall patient satisfaction, a concept that is already inherent to our specialty, particularly with respect to patients pursuing aesthetic surgery.1
Despite the potential positive effects of the ACA, this study demonstrates that the majority of surveyed plastic surgeons do not support the ACA. Overall, respondents feel that it will negatively affect their practice volume, reimbursement, and the specialty in general. Interestingly, almost one-fourth of respondents feel that the ACA will have no effect on preoperative counseling and shared decision-making, and over half of all respondents do not believe that the ACA will increase access, increase insurance coverage, or promote innovation with respect to plastic and reconstructive procedures.
Several polls and surveys have aimed to assess medical professionals’ understanding and perceptions of the ACA.4,6,8,9 In a survey of 1232 medical students from 10 medical schools, 54% of students agreed with the statement, “I understand the major provisions of the ACA.”6 Seventy-two percent agreed with the notion, “I support [the Act] but think more reform is needed.”6 The majority (45%) of students self-identified as “liberal.”6 Similarly, physicians as a group have been surveyed to gauge the profession’s opinions of recent health-care reform.4,8,9 One study revealed that 83% of physicians felt at least somewhat knowledgeable about the ACA.4 Interestingly, 28% gave the Act a grade of “B” while 38% graded the ACA as “F,” suggesting a polarized distribution with the majority of respondents being either very “for” or very “against” the ACA. Upon review of results of each of the 2 aforementioned surveys, there seem to be discrepancies between medical student and practicing physician responses, which perhaps reflect differences in political views and practicing physicians’ increased involvement with the intricacies of the health-care system.
It is difficult to hypothesize exactly how the ACA will affect cost, access, and quality with respect to plastic surgery. The Center for Medicaid Services estimates that with the ACA, there will be a projected increase of 0.2% in the percentage of GDP spent on health care by 2020 ($46 billion), but surmises that the cost of expanding coverage to millions of uninsured Americans will minimize costs in the longer term.5,10 With 36% of respondents offering a grade of “F” to the ACA, plastic surgeons seem to oppose the ACA. With so many opponents, one could argue that more involvement in legislation and policy-making by our specialty may be of benefit for both surgeons and patients seeking plastic and reconstructive procedures and consultations.
Several articles have discussed physicians’ role in political process. A historical review of physician involvement in US Congress cites that physicians comprised 1.1% of all congressional members between 1960 and 2004; this is in contrast to the signers of the Declaration of Independence, where 10.7% were physicians.11 Kraus and Suarez11 call for increased participation in political endeavors by our profession and argue that physicians as a group have the unique opportunity to supersede bipartisan battles that propel much of the debate on health-care reform. In a recent letter in Plastic and Reconstructive Surgery, Patel et al12 reference the Independent Payment Advisory Board, suggesting that plastic surgeons should participate in local and national politics, lest we risk further decision-making by lawmakers who may not understand “the intricacies” of disease states and decision-making relevant to plastic surgery. One way to cultivate a drive to be leaders in health-care policy may be to incorporate more legislative-based education and emphasis on current events13 into medical school and residency training.6,13,14
As part of a drive for lifelong learning and Continuing Medical Education, plastic surgeons can and should become knowledgeable about the ACA; doing so will benefit individual practices and the specialty. There are several online resources for learning about the details and aims of the Act and for becoming more involved in policy and advocacy.15–18 The American Medical Association offers informational documents and online links regarding participating in the ACA and how it may affect patients and physicians.15 A book of articles and primers from the American College of Surgeons provides insight into the changing health-care system and its relevance to surgeons both now and in years to come.16 Finally, the ASPS Web site (plasticsurgery.org) contains resources for educating plastic surgeons on the ACA, details ways in which the ASPS is involved in advocacy,17 and describes the role of PlastyPAC, a bipartisan Political Action Committee that represents plastic surgery’s voice in legislation.18
The ACA is here to stay and all specialties, including plastic surgery, will be affected by it. This survey suggests that plastic surgeons feel that they understand the basic components of the ACA although many respondents are unsure as to how it will affect cost, quality of services, outpatient surgery centers, and shared decision-making. The majority of surveyed plastic surgeons feel negatively about the ACA and its anticipated changes for both patients and physicians. Despite these negative sentiments, the changes experienced may not be as drastic as expected, and some of these changes may be positive for plastic surgeons and patients pursuing plastic and reconstructive procedures. Although the largest group of ASPS members is in solo practice (>40%), the national trend is for an increasing number of future physicians to be “employed physicians.” These employed physicians will undoubtedly be affected by the changes related to the ACA, such as formation of Accountable Care Organizations and changes in reimbursement methodologies. The ASPS and other plastic surgery organizations need to provide educational sessions and information to their members regarding the impact of the ACA and how we can thrive in the new environment. An increased understanding of “Obamacare” and its tenets, as well as increased participation in the legislative process, will benefit individual practices and the entire specialty.
1. Chen JT, Israel JS, Poore SO, et al. The affordable care act: a primer for plastic surgeons. Plast Reconstr Surg. 2014;134:830e–837e
3. Deloitte Center for Health Solutions. Deloitte 2012 survey of U.S. health care consumers: The performance of the health care system and health care reform. Available at: http://www.deloitte.com
. Accessed November 28, 2013
4. Jackson Healthcare, LLC. Survey: Physician Attitudes on the Affordable Care Act. Survey conducted 2012. Available at: http://www.jacksonhealthcare.com
. Accessed November 28, 2013
5. Blendon RJ, Benson JM. Public opinion at the time of the vote on health care reform. N Engl J Med. 2010;362:e55
6. Huntoon KM, McCluney CJ, Scannell CA, et al. Healthcare reform and the next generation: United States medical student attitudes toward the Patient Protection and Affordable Care Act. PLoS One. 2011;6:e23557
7. Kocher R, Emanuel EJ, DeParle NA. The Affordable Care Act and the future of clinical medicine: the opportunities and challenges. Ann Intern Med. 2010;153:536–539
8. Keyhani S, Federman A. Doctors on coverage—physicians’ views on a new public insurance option and Medicare expansion. N Engl J Med. 2009;361:e24
11. Kraus CK, Suarez TA. Is there a doctor in the house? Or the Senate? Physicians in US Congress, 1960-2004. JAMA. 2004;292:2125–2129
12. Patel A, Shah A, Singh D, et al. Protecting plastic surgery under the affordable care act. Plast Reconstr Surg. 2013;131:316e–317e
13. Lee BY. Current events: an important currency. Acad Med. 2005;80:732
14. Lee BY, Tsai AG, Turner BJ. Medical student, medicine resident, and attending physician knowledge of the Medicare Prescription Drug Modernization and Improvement Act of 2003. Teach Learn Med. 2007;19:91–94
16. Hoyt DBAmerican College of Surgeons. . Our changing health care system since the inception of the Affordable Care Act: A collection of articles and primers from the American College of Surgeons. Our Changing Health Care System. 2014 Chicago, IL American College of Surgeons In: Available at: https://www.facs.org/advocacy/federal/health-care-reform
. Accessed October 18, 2014
18. American Society of Plastic Surgeons. . “About PlastyPAC.” Legislation & Advocacy: PlastyPAC. 2014. Available at: http://www.plasticsurgery.org
. Accessed October 18, 2014.