What Does the SGR Fix Really Mean to Doctors?

After More Than a Decade, a "Doc Fix": 5 Key Points

National Physicians Call-In Day on Tuesday, March 24. Please help spread the word to your colleagues - we want as many physicians as possible to be flooding the phone lines of their U.S. representatives to make the case for SGR repeal now! Make sure you call on Tuesday: (800) 833-6354.

After 17 years of kicking the can down the road it seems the SGR  will blow away in a  cloud of dust, leaving what ?

In this era of novel payment models, accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and other acronyms and initiatives, some have pondered whether the SGR is really still significant.  It is true, the landscape of  reimbursement and health financing barely resembles that of 1997 when the SGR (Sustainable Growth Rate) adjustment was designed to  counteract the increase in the senior demographic becoming eligible for Medicare.  

Medicare payments barely resemble those of 1994 when draconian cuts were made to fees to physicians unrelated to an SGR.  Cuts of 2 to 5 % had been expected each year, and now 15 years later the SGR lies fallow like an abandoned ICBM rusting in the South Dakota plains.

Chronic diseases have become a major category of spending, new treatment models, payments dependent  upon outcomes, quality of care, and a decreased emphasis on a strict fee for service. The new buzz acronym is P4P (Pay for performance).

The conversion to payments for quality of outcomes is not  a total abandonment of fee for service. Not at all !.  It is not a  pre-paid formula, or a payment model designed like a DRG (Diagnosis related group) where payments are tied to the disease being treated.

What is occuring is the use of fee for service with a bonus incentive/penalty for non compliance. This will be administered with a thick overlay of algorithms following a mystery calculus of big data forthcoming from meaningful use standards built into the federal HIT system.  The system of EHRs and the HIEs still yet to be built are the bedrock of this new as yet implemented feature of the ACA.  Never you mind the additonal acronym of  ACO (Accountable Care Organization).

Yes, our nation is one of  'Exceptionalism" (except for this, or for that).

So the SGR was not important.....it never was, just to use as a negotiating point and used as a bishop at the last minute in the war on physicians, who invested untold millions of dollars via the AMA and other physician group lobbying on the hill the past 15 or more years.

The final shovel of dirt will fall on the SGR casket with the change to ICD-10 making all previous ICD 9 codes obsolete and fossilized.

The SGR never had a chance to become a fossil, rather it never lived and it's DNA became extinct before it was born.  Conceived, yes, then miscarried before it's birth.

National Physicians Call-In Day on Tuesday, March 24. Please help spread the word to your colleagues - we want as many physicians as possible to be flooding the phone lines of their U.S. representatives to make the case for SGR repeal now! Make sure you call on Tuesday: (800) 833-6354.

House Speaker John Boehner and Minority Leader Nancy Pelosi have put forth a deal that would result in a vote on a full SGR repeal. It would also reauthorize the Children's Health Insurance Program (CHIP) before the latest (of 17) SGR "patches" expire on April 1. The Congressional offices I've spoken with expect there to be a vote by Thursday. What chance does this have and what do you need to know about this proposed legislation?

Point 1. This (Still) Matters

"It's not a doc fix. It's a fix for America's seniors so that they can continue to see their doctors under Medicare." –Pelosi^[1]

Point 2. Approval Is Not a Sure Thing

This "fix" is essentially no different from the bipartisan, bicameral (House and Senate) SGR Repeal and Medicare Provider Payment Modernization Act of 2014

Point 3. Organized Medicine Is United in This Effort

Last Monday, a letter^[2] endorsed by over 750 physician membership organizations was delivered, urging Congress to pass legislation, based on last year's bill, before the SGR patch expires on April Fool's Day.

Point 4. The Bill Does More Than Just Fix the SGR (And Should Do Still More)

Throughout lobbying efforts restoring Medicaid Primary Care Pay Parity has been a linked objective. Additionally, the Medicare Primary Care Incentive Program, which has provided internists and other primary care physicians 10% bonus payments on their office visits and other designated services since 2011, is set to expire at the end of 2015.

Point 5. The Time to Act Is Now

Medicine is not receiving everything it has asked for. Medicine is not receiving undue gifts or treatment. Primary care, which takes care of vast numbers of Medicare recipients in this country, remains dramatically undervalued to the great detriment of public health and national economic productivity, and is still inhibited from delivering the moral breadth and depth of services smoothly and thoroughly across the nation's towns and neighborhoods for which those of us in the profession chose this life.

It is essential that every physician and every patient who receives, or hopes to receive, primary care call their representatives, and especially their Senators, NOW to encourage an affirmative vote prior to the April recess.

National Physicians Call-In Day on Tuesday, March 24. Please help spread the word to your colleagues - we want as many physicians as possible to be flooding the phone lines of their U.S. representatives to make the case for SGR repeal now! Make sure you call on Tuesday: (800) 833-6354.

Attribution :  Medscape

Supreme Court Ruling Could Limit Medical Board Authority

State medical boards may find it harder to fence off the practice of medicine from nonphysicians — think nurse practitioners — in the wake of today's Supreme Court decision in a case about teeth whitening.

In a 6–3 vote, the high court ruled that North Carolina's dental board violated the Sherman Antitrust Act when it shut down nondentists who were whitening teeth in malls and beauty shops because the board, composed mostly of practicing dentists, was not actively supervised by the state. Active supervision, the court said, would have shielded the board from a Sherman violation.

"[The Sherman Act] does not authorize the states to abandon markets to the unsupervised control of active market participants, whether trade associations or hybrid agencies," the court said, upholding a move by the Federal Trade Commission (FTC) to block the dental board's actions in the name of fair competition.

Dissenting from the majority opinion were Associate Justices Samuel Alito Jr, Antonin Scalia, and Clarence Thomas.

The American Medical Association (AMA) and other medical societies had asked the Supreme Court to hear the case — and uphold the decision of the North Carolina dental board — in light of the antitrust implications for state medical boards.

"If state licensing decisions are subject to invalidation by federal agencies with no particular expertise in the healing arts, then those federal agencies will become the final arbiters of matters of public safety, tasks that they are ill-equipped to perform," the AMA and its allies stated.

The medical societies warned that if the FTC got its way, medical boards might be loath to crack down on nonphysicians engaged in "the illegal practice of medicine" for fear of triggering an antitrust suit. They cited the example of nurse practitioners who provide services that were beyond their qualifications without any physician supervision.

Rallying behind the FTC in the Supreme Court case were the American Nurses Association, the American Association of Nurse Practitioners, the American Association of Nurse Anesthetists, the American College of Nurse Midwives, and the National Association of Clinical Nurse Specialists. In a friend-of-the-court brief, these associations said that active state supervision was needed for physician-dominated medical boards because they have a history of unfairly limiting the scope of practice for nurses.

In response to today's ruling, AMA President Robert Wah, MD, said that his organization would work with other medical societies "to secure policy changes to reinforce long-held antitrust protections" for state medical boards.

"The AMA agrees with Justice Alito, speaking for the three dissenting justices, that today's decision 'will spawn confusion' by creating far reaching-effects on the jurisdiction of states to regulate medicine and protect patient safety," Dr. Wah said in a statement emailed to Medscape Medical News.

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Medicare's Sustainable Growth Rate--(SGR)

As reported in iHealthbeat, a publication of the California Health Care Foundation (CHCF)

It has been over 15 years since Congress enacted the SGR, an act which has been put on hold each year since t hen.  The accumulative value is now over 20%, which if enacted would reduce Medicare payments to providers by 20%.

Each year health providers have lobbied Congress to keep the SGR on hold.

Since 1994 many changes have occured in the administration of CMS and payment reforms.  As Congress considers repealing the SGR other changes have occured, the Affordable Care Act and other changes in payment models from fee for service payment to value based payments.

SGR Replacement Bill Has Big  Implications for Health IT On Thursday, Senate and House lawmakers introduced bipartisan, bicameral legislation (HR 1470) to permanently replace Medicare's sustainable growth rate formula that includes several health IT provisions, Modern Healthcare reports (Tahir, Modern Healthcare, 3/19). Congress last year approved a short-term delay to scheduled reductions to Medicare physician reimbursement rates called for by the SGR. Providers face about a 21% reduction in Medicare reimbursement rates unless Congress acts by April 1, 2015 (Hughes, Wall Street Journal, 3/19). Meaningful Use Provisions The new legislation would replace the SGR with a merit-based incentive payment system that would consolidate several federal incentive programs, including the meaningful use program, physician quality reporting system and value-based modifiers, into one value-based payment reporting system. Under the 2009 economic stimulus package, providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments. Specifically, the SGR replacement measure would: Sunset meaningful use penalties (Gold et al., "Morning eHealth," Politico, 3/20); Make eligible professionals who meet the program criteria eligible for a bonus (Modern Healthcare, 3/19); Require eligible professionals to demonstrate that they have not "knowingly and willfully taken action ... to limit or restrict the compatibility or interoperability of the certified EHR technology"; and Encourage medical professionals to use EHRs even if they are not eligible for the meaningful use program via incentives, such as streamlined reporting of quality metrics (Goedert, Health Data Management, 3/20). The legislation also would mandate that HHS work with stakeholders to develop measures to quantify interoperability by July 2016 ("Morning eHealth," Politico, 3/20). Additional Health IT Provisions The bill also would: Clarify that Medicare is able to pay for telehealth services in alternative payment models ("Morning eHealth," Politico, 3/20); and Incentivize telehealth services and remote patient monitoring by including them as clinical practice improvement activities (Modern Healthcare, 3/19). In addition, the legislation would call for several reports, including: A study by HHS on ways to potentially assist providers with comparing EHR systems, which would be due in one year ("Morning eHealth," Politico, 3/20); and A study by the comptroller general assessing how insurers are encouraging remote patient monitoring and the obstacles to more widespread use of remote monitoring technology in Medicare (Modern Healthcare, 3/19). The replacement legislation does not mention the ICD-10 transition. It seems that the simplicity of repealing the SGR has bcome obfuscated by all of the ramifications of the Affordable Care Act, transitioning to a value-based payment model, HIT incentives, the patient quality reporting sysem (PQRS). The bottom line is that savings afforded by the Affordable Care Act combines with incentives may equal or outweigh the theoretical reductions of the SGR, rendering the SGR irrelevant.

The Conundrum of Blue Shield of California

Officials Revoke Blue Shield of California's Tax-Exempt Status

Blue Shield has always served as one of the beacons of the health insurance industry.

The Corporate History of Blue Shield of California  It was formed in 1938 by the California Medical Associaton

What happened to the Mission and Values of Blue Shield  ? "  Was the fox in the henhouse ?

Their website describes their Code of Conduct"

 Blue Shield of California's Code of Conduct (PDF, 1.3 MB)

The California Franchise Tax Board has stripped the not-for-profit Blue Shield of California of its tax-exempt status, the Los Angeles Times reports.

Background

According to the Times, the tax-exempt status revocation comes as Blue Shield has faced criticism over its:

• Executive pay;
• Rate hikes; and
• $4.2 billion surplus.

For Care,  Not for Profit (what does Blue Shield mean?). from the web site

As a not-for-profit health plan, we put the care of our members before profits. See what we mean by:

Affordable Care 
Comprehensive Coverage and Service
Access to Quality Care
Doing the Right Thing

According to the Times, Blue Shield's surplus at the end of 2014 was four times as much as what the Blue Cross and Blue Shield Association requires insurers to stockpile to cover future claims.

Advocates also have criticized Blue Shield for failing to serve Medi-Cal beneficiaries. Medi-Cal is California's Medicaid program.

In addition, critics have raised concerns about Blue Shield's lack of transparency. For example, the insurer's 2012 filings did not list any executive employees by name.

Michael Johnson, former public policy director at Blue Shield, said that the insurer has been "shortchanging the public" for years. Johnson said that he plans to launch a campaign to convert the insurer into a for-profit company and force it to return billions of dollars to the public.

Details of Revocation

A California Franchise Tax Board spokesperson declined to comment on why Blue Shield's tax-exempt status was revoked, but officials have ordered the insurer to file tax returns for each year back to 2013.

On Tuesday, Blue Shield said it would protest the decision.

Blue Shield spokesperson Steve Shivinsky said, "Blue Shield as a company and management team firmly believes it is fulfilling its not-for-profit mission and commitment to the community."

Reaction

Anthony Wright, executive director of Health Access, said, "It's important to have this debate over Blue Shield's public-service mission and how they are fulfilling it."

In addition, Dena Mendelsohn, a health policy analyst at Consumers Union, said that the insurer's "lack of transparency makes it hard to understand whether Blue Shield is holding up their end of the bargain with the public" (Terhune, Los Angeles Times, 3/18).

BigHealth has Made the Hospital a Hostile Environment for the Solo Private Practitioner

It effects your health care

Attributed to Bruce Davis, M.D.

Contracts | Medical Blog

March 19, 2015

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Bruce Davis, MD 
[click for more info]

" BigHealth has made the hospital a hostile environment for the solo private practitioner. They have almost completely driven out the Internists. They are limiting the freedoms of the General Surgeon, and have made specialists into mere technicians."

The hospital where I do much of my elective surgery recently terminated the contract it had with a large Hospitalist group and announced plans to hire Hospitalists directly as hospital employees. A less publicized part of that move is an attempt through the Credentials and Bylaws committees of the medical staff to terminate the credentials of physicians who are associated with that group under an ‘exclusive contract’ provision in the hospital bylaws. In essence that provision states that certain areas are recognized as being best served by an exclusive contract and that physicians credentials to admit and treat patients under those arrangements are contingent on the continued contract.

This has been traditionally applied to services such as Radiology, laboratory services, and Pathology. More recently (20 years) it was applied to Emergency Medicine. At my hospital is has not been applied to Anesthesia, Cardiology, or Hospitalist services. The administration would like to change that.

Standing in the way is specific language in the current bylaws that addresses this eventuality for those areas where exclusive contracts have not previously existed. The proposed change in the bylaws language was put forth by several employed physicians and almost got through committee until a sharp-eyed private practice physician on the committee noticed it and had it removed. (No, it wasn’t I who did that, but I applaud his vigilance)

Why should I care? After all, this is about Hospitalists. I rarely, if ever, use them for my own patients and the group involved does not consult me with any regularity. It would seem that I don’t have a dog in this hunt. But I do. And so does every private practice physician or surgeon who sees patients at this hospital.

“This is just the latest in the low level war between private practice and the big healthcare companies (and their silent partners in the government). “

This is just the latest in the low level war between private practice and the big healthcare companies (and their silent partners in the government). Under the guise of CMS/Medicare requirements, ‘best practice guidelines’, hospital service contracts, and the control of information through the Electronic Medical Record, BigHealth has made the hospital a hostile environment for the solo private practitioner. They have almost completely driven out the Internists. They are limiting the freedoms of the General Surgeon, and have made specialists into mere technicians.

To be sure, we have allowed this to happen to ourselves through complacency, inability to cooperate with each other, and a willingness to cede authority to those with the desire to take it. Unfortunately, those willing to take that authority are employees of or shills for the company. The voice of the private practice doctor has nearly been stilled in favor of ‘clinical consensus groups’ and case managers who dictate everything from antibiotic choice to lengths of stay.

I urge all physicians and surgeons who are still in private practice to stay involved with the governance of your respective hospitals. The people in charge of healthcare these days do not have your best interest at heart. You may or may not believe that private practice is a good business model, but in my experience it is the best guardian of the patients best interest. Don’t cede control to the bureaucrats and bean counters.

- See more at: http://www.physiciansweekly.com/contracts/#comment-69660

Congress Considering Repealing the Sustainable Growth Rate

This is not a test. Repeat: This is not a test. Serious movement is underway in Congress to permanently repeal the sustainable growth rate (SGR) before the March 31 deadline; repeal legislation, H.R. 1470/S. 810 is expected on the floor of the U.S. House of Representatives next week. With so few legislative days left before the deadline, Congress is going to have to thread the needle to get this done - and that can only be accomplished if they know their constituents demand action and not the status quo. There are groups on the other side of the issue who don't want to see this get done, and as you read this they're mobilizing their grassroots networks to defeat it. That's why we need you now, more than ever, to keep the pressure on Congress to make sure SGR reformfinally gets across the finish line by contacting your legislators through every means available and asking them to vote yes on H.R. 1470/S. 810. Call your U.S. representative and senators using the AMA's toll-free Physicians Grassroots Hotline: (800) 833-6354. Send an urgent email to your lawmakers reinforcing the need for SGR repeal now - Click Here! Contact key legislators still undecided on this most critical issue directly through their own social media channels and share with your own Facebook friends and Twitter followers as well - Click Here! This is urgent. There is still time for Congress to pass meaningful SGR reform before the deadline, but it has to act now! P.S. The AMA is promoting a National Physicians Call-In Day on Tuesday, March 24. Please help spread the word to your colleagues - we want as many physicians as possible to be flooding the phone lines of their U.S. representatives to make the case for SGR repeal now! Make sure you call on Tuesday: (800) 833-6354. Click the link below to log in and send your message: https://www.votervoice.net/link/target/ama/JQRErQF75.aspx

This message is brought to you courtesy of: For more information, please visit:  AMA Physicians' Grassroots Network   AMPAC   Click here to unsubscribe from this mailing list.

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The WEGO Awards

The WEGO Awards may be the next Academy Awards for Health Care Social Media

Death of a Digital Darling

GIGAOM has closed down...a sad day, for the complete story....... how long can a start up take ?

Geriatric Crisis in Process

WHEN SUSAN BLOCK, a professor of psychiatry and medicine, started practicing medicine more than three decades ago, there was no formal field of palliative care. Today, it is an established specialty with a growing presence in the U.S. healthcare system. The number of hospital-based programs nearly tripled between 2000 and 2010, and most large hospitals now have palliative-care teams, according to the Center to Advance Palliative Care, a national organization aimed at expanding these services. Still, Americans living in certain geographic regions (for example, where small hospitals are the norm) have limited access to this comfort-centered approach to serious illness.

We all can see how the relative numbers of people over the age of 65 has expanded in the past three decades.  This is not only due to  aging of the baby boomer demographic, but also due to great strides in treating chronic disease and the recognition of life style and nutrition upon the aging process. Will we live longer ? Perhaps not, but the goal actually is to live a good quality of life, then die quickly.

Everyone wishes to live healthier and longer live , hence the overwhelming menu of snake oil medicine, herbs and substances which has become a multi-billion dollar business.

Statistics reveal that for the aged infirm options are becoming narrower due to the lag in providing suitable living arrangements for many.

Palliative care emerged with the hospice movement of the 1960s, but it wasn’t until 2006, after a strategic campaign led by Block and other advocates, that hospice and palliative medicine became a defined medical specialty. The move marked “a critical step in achieving legitimacy and a seat at the table in American medicine,” says Block, chair of the psychosocial oncology and palliative care department at Dana-Farber Cancer Institute and Brigham and Women’s Hospital. “It has raised the stature of the field.

There are now nearly 100 hospice and palliative-medicine fellowship programs around the country; Harvard’s fellowships in palliative care educate about a dozen doctors, nurse practitioners, and social workers annually.

Palliative care is associated with higher quality of life and lower costs through fewer and shorter hospital stays, less intensive treatments, and more hospice use, so it’s an attractive option in the context of healthcare reform. But experts worry about the future. There’s already a serious national shortage of hospice and palliative-medicine physicians (one study estimates a gap of at least 6,000), and demand will likely grow as baby boomers age, the number of Americans with chronic conditions (such as heart disease, diabetes, cancer, and dementia) soars, and more providers in community settings, like outpatient clinics, aim to offer palliative care as well. The global demand is rising, too; according to the World Health Organization and Worldwide Palliative Care Alliance, only one in 10 people who need these specialized services receives them—and most palliative care is provided in high-income countries.

In addition to the lag in numbers of  professionals there also is a deficit in  bed capacity for the aged infirm. At the moment we are caught in the effort to reduce hospital admissions, length of stay, leaving many to find suitable respite.

Medicare does not provide long term insurance.  Long term insurance must be acquired elsewhere. Hospice care is for the terminally ill, who have assigned medicare medical benefits toward hospice care. 

Most patients do not have long term insurance due to costs. And there are no provisions for long term care in the affordable care act, thus far.

How will the void be filled. I am interested in  your comments.

Institute of Medicine in the United States currently studying the ethical and social implications of mithochondrial replacement therapy

Following the approval of legislation to license clinics to perform mitochondrial replacement therapy in the United Kingdom, United States may now be following suit. The US Food and Drug Administration (FDA) requested the Institute of Medicine (IOM) to produce a “consensus report regarding the ethical and social policy issues related to genetic modification of eggs and zygotes to prevent transmission of mitochondrial disease”. Subsequently, IOM set up a committee which plans to meet approximately five times over the course of the study. The first committee met in January 2015, the second is expected to be in March 2015, which will include a 2 day public workshop in addition to a closed committee session. The third committee will meet in May 2015, which will include a public comment session with two closed committee meetings, during which the committee will draft and finalise the final report. OrphaNews will provide readers with information on the proceedings of these meeting as they become available. You can also receive updates from the IOM website . 

Mitochondrial DNA

Human DNA is found in the chromosomes of cell, and inside  mitochondria in the cytoplasm.  Mitochondria are the power generator of the cell providing the intermediary metabolites for cellular metabolism. The presence of DNA defects in this organelle can cause serious disease. The defects are  inheritable. The key difference in inheritability of mitochondrial DNA is that the mitochondrial DNA is transmitted by the female in  her ovum cytoplasm.

The List of Mitochondrial Disease

Audio report - William Gahl MD

This will be the first time mitochondrial DNA therapy is attempted.  Previous DNA therapy has been focused on nuclear DNA diseases, such as Cystic Fibrosis, 

                   Nuclear DNA Disease

Health Problems with  Mitochondrial Disorders

Hospital Evaluations by Social Media: A Comparative Analysis of Facebook Ratings among Performance Outliers.

BACKGROUND
An increasing number of hospitals and health systems utilize social media to allow users to provide feedback and ratings. The correlation between ratings on social media and more conventional hospital quality metrics remains largely unclear, raising concern that healthcare consumers may make decisions on inaccurate or inappropriate information regarding quality.

OBJECTIVES
The purpose of this study was to examine the extent to which hospitals utilize social media and whether user-generated metrics on Facebook(®) correlate with a Hospital Compare(®) metric, specifically 30-day all cause unplanned hospital readmission rates.

DESIGN AND PARTICIPANTS
This was a retrospective cross-sectional study conducted among all U.S. hospitals performing outside the confidence interval for the national average on 30-day hospital readmission rates as reported on Hospital Compare. Participants were 315 hospitals performing better than U.S. national rate on 30-day readmissions and 364 hospitals performing worse than the U.S. national rate.

MAIN MEASURES
The study analyzed ratings of hospitals on Facebook's five-star rating scale, 30-day readmission rates, and hospital characteristics including beds, teaching status, urban vs. rural location, and ownership type.

KEY RESULTS
Hospitals performing better than the national average on 30-day readmissions were more likely to use Facebook than lower-performing hospitals (93.3 % vs. 83.5 %; p < 0.01). The average rating for hospitals with low readmission rates (4.15?±?0.31) was higher than that for hospitals with higher readmission rates (4.05?±?0.41, p < 0.01). Major teaching hospitals were 14.3 times more likely to be in the high readmission rate group. A one-star increase in Facebook rating was associated with increased odds of the hospital belonging to the low readmission rate group by a factor of 5.0 (CI: 2.6-10.3, p < ?0.01), when controlling for hospital characteristics and Facebook-related variables.

CONCLUSIONS
Hospitals with lower rates of 30-day hospital-wide unplanned readmissions have higher ratings on Facebook than hospitals with higher readmission rates. These findings add strength to the concept that aggregate measures of patient satisfaction on social media correlate with more traditionally accepted measures of hospital quality.

Author Opinion

The results of this study are not surprising. Popular publication reviews are often based upon  public opinion on discharge as well as statistical metrics for excellence. Facebook uses similar metrics in it's reviews of hospitals.

Upcoming Topics:

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How to Teach Doctors Empathy

"Being a good doctor requires an understanding of people, not just science."

Teaching doctors how to engage more and lecture less

Studies have linked empathy to greater patient satisfaction, and better outcomes

Medical Students' Views and Knowledge of the Affordable Care Act: A Survey of Eight U.S. Medical Schools.

The future for the Affordable Care Act may well live in the minds of the current generation of medical students and trainees and not the electorate or political party.  In reality the future of medicine is in their destiny.  

Journal of General Internal Medicine:   March 10, 2015

BACKGROUND
It is not known whether medical students support the Affordable Care Act (ACA) or possess the knowledge or will to engage in its implementation as part of their professional obligations.

PARTICIPANTS
All 5,340 medical students enrolled at eight geographically diverse U.S. medical schools (overall response rate 52 % [2,761/5,340]).

CONCLUSIONS
The majority of students in our sample support the ACA. Support was highest among students who anticipate a medical specialty, self-identify as political moderates or liberals, and have an above-average knowledge score. Support of the ACA by future physicians suggests that they are willing to engage with health care reform measures that increase access to care.

KEY RESULTS
The majority of respondents indicated an understanding of (75.3 %) and support for (62.8 %) the ACA and a professional obligation to assist with its implementation (56.1 %). The mean knowledge score from nine knowledge-based questions was 6.9?±?1.3. Students anticipating a surgical specialty or procedural specialty compared to those anticipating a medical specialty were less likely to support the legislation (OR?=?0.6 [0.4-0.7], OR?=?0.4 [0.3-0.6], respectively), less likely to indicate a professional obligation to implement the ACA (OR?=?0.7 [0.6-0.9], OR?=?0.7 [0.5-0.96], respectively), and more likely to have negative expectations (OR?=?1.9 [1.5-2.6], OR?=?2.3 [1.6-3.5], respectively). Moderates, liberals, and those with an above-average knowledge score were more likely to indicate support for the ACA (OR?=?5.7 [4.1-7.9], OR?=?35.1 [25.4-48.5], OR?=?1.7 [1.4-2.1], respectively) and a professional obligation toward its implementation (OR?=?1.9 [1.4-2.5], OR?=?4.7 [3.6-6.0], OR?=?1.2 [1.02-1.5], respectively).

Author's Opinion

Judging from the survey result the majority of trainees support the ACA and will work with the new system.  This is not surprising. Young physicians are altruistic and by and large are not driven by monetary aspects.  of health care. Few are knowledgable about the inner workings of the payment system until they enter practice. It would be interesting to survery physicians in age groups centering around their length in practice. Perhaps the quote, "Old dogs do not learn new tricks"  would be appropriate.