How is Obamacare affecting outpatient surgical facilities? Our poll of physicians and administrators strongly reflects the deep divide that characterizes the national debate about healthcare reform. Some say it's hurting business. Some say it's helping. Some say it goes way too far. Some say it doesn't go far enough. Almost half say they'd like to see the law repealed, but more than half wouldn't, or at least wouldn't unless there's a better way to reduce the vast number of uninsured Americans. Others say patience is the key.

"It's a work in progress," says Charlene Conilogue, administrator of the (Pocatello) Idaho SurgiCenter. "Anything's that's put into law usually has to be tweaked over a number of years for it to become what it needs to be to benefit people."

Despite strong and often adversarial views, 2 refrains are common to both proponents and opponents. The first is that deductibles and co-pays associated with the ACA are so high that many of the newly insured are still failing to get the care they need.

"When people come for a procedure, we have to take them into the business office and explain that there's $3,000 or $1,500 they need to pay up front," says Jeffrey Purtle Sr., CRNA, who practices at Bob Wilson Memorial Grant County Hospital in Ulysses, Kan. "We've had at least 20 cancellations since the first of the year for that reason. People can't come up with the money."

"I look at it as a bait-and-switch," says Glenn N. Pomerance, MD, president and medical director of Pomerance Eye Center in Chattanooga, Tenn. "They made the insurance available to the patient, but they made it impossible to use. Patients have to pay the first $2,500, $3,500 — I've heard as much as $6,000 — before the insurance kicks in. That's a lot of money."

Additionally, the fact that patients take out policies is no guarantee that they'll keep paying their premiums, says Nancy Nicoll O'Neill, administrator of Gastrointestinal Healthcare in Raleigh, N.C. That, she says, can leave providers holding the bag.

"We have to be very diligent about checking," she says. "The insurance company will tell you if the premium hasn't been paid but it's still in the 90-day grace period. But if they come in on their 88th day and have a colonoscopy, then don't pay their premium, they get dropped and our claim gets denied. If we know when the grace period is up, we can move the procedure out to make sure they have paid."

But that means spending time on the phone and hoping that the person on the other end can answer the question. "A lot of practices do not have the staff to do that," she says.

Who's winning?
The second common theme is that the ACA's greatest beneficiaries are neither patients nor providers, but insurance companies. After all, if more people are paying premiums, but still aren't getting the care they need, someone else must be making out.

"Obamacare had nothing to do with Obama or care," says Robert Kotler, MD, FACS, of the Summit Surgery Center in Beverly Hills, Calif. "The insurance industry merely wanted more customers. Young and healthy customers, of course. That's all you need to know. They wrote the bill and their puppets in Congress signed it. Done deal. Everyone's happy except the patients."

Success stories
Despite the perceived shortcomings, however, most aren't ready to scrap the whole law. Asked whether they'd like to see the ACA repealed, 47% of our respondents said yes, 27% said no and 26% said only if there's a better way to reduce the number of uninsured Americans.

Chris Ibinkunle, MD, MBA, CEO of SurgiCare Gwinnett (Ga.) ASC, doesn't favor repeal, but would like to see the law improved. "It's cumbersome," he says, "and lacks several important components, such as tort reform, commercial payer oversight and simplification to reduce administration costs."

Others say the law has done nothing but help their facilities, like Randy Huffman, RN, regional administrator of the Weston Outpatient Surgical Center in Weston, Fla. "The Affordable Care Act has been a great thing for our center," says Mr. Huffman. "We're seeing more patients and getting paid fairly for what we provide."

George Tway, RT, center administrator at Galileo Surgery Center in San Luis Obispo, Calif., says the ACA has changed his vacation strategy — in a good way. "I've been in this surgery center since it started in 1999," he says. "The first quarter of every year, business used to drop off 25 to 30%, as people paid their deductibles. There was always a rush to get stuff done in November and December, and then January was a good time to take vacation. But this year and last year, that didn't happen. Business has stayed steady."

For others, the ACA has helped expand their payor bases, which can only help. "Our philosophy is that some payment is better than no payment," says Katherine Halverson Carpenter, RN, MBA, CNOR, director of perioperative and obstetrical services at the University of Colorado Hospital. "Our uncompensated care is a huge dollar amount. Reducing those numbers, even though payment may or may not cover our direct costs, is still better than where we were before."

And for every yin, there seems to be a yang.

"Our business is down by 40%," says a facility chief at a Pittsburgh ASC. "Increased deductibles and co-payments for commercial insurance plans have [hurt] our overall business. I find it hard to believe there is anything 'affordable' about it."

Not a fan
Doctors appear to be slightly more hostile to the law than facility managers, with 50% of our physician-respondents favoring outright repeal. The reasons echo many of the concerns expressed by opponents through the years.

"There's a lot more paperwork," says Dell Smith, MD, a surgeon in Twin Falls, Idaho. "It's taken up all of my previously free time. There's no time left for my family or for relaxation."

In all, 72% of the doctors we polled say they're dealing with either "more" paperwork or "a lot more" paperwork since the law went into effect. "We're focusing on ways to make us look good on paper and please the government," says an anesthesiologist in Hawaii. "We're forgetting the patient. I have to take care of the patient and watch the computer at the same time."

That frustration has led some to the brink of throwing in the towel. "Since the bureaucrats make the decisions now," says a Tennessee anesthesiologist, "I've changed from an independent practice to physician-employee status. It's the increased headache of paperwork, decreased reimbursement and further impairment of the patient-physician relationship. I'm considering early retirement if this continues."

Govern-ment-mandated EMRs are also a sore spot. "I don't need anything to extend my day, and EMRs have extended my day," says Mr. Purtle "It's asking: What's your hot water heater set at? Do you have a gun in your house? How many sexual partners do you have? It's absolutely ridiculous."

Nor, he says, is information being constructively shared. "When we send patients to other hospitals, they don't have a clue what we've done here, and we don't have a clue what they're doing there. There's no integration, because every hospital in this area has a different computer system."

What's the alternative?
Our survey responses underscore the difficulty of bridging the gap between recognizing the various problems associated with healthcare delivery, both pre- and post-Obamacare, and knowing how to solve them.

"I think (the Affordable Care Act) was a noble and necessary change to the healthcare insurance business," says Dr. Pomerance. "The only problem is that functionally, it doesn't work. The effort to not have pre-existing conditions affect getting insurance was great, but here, too, there was a bait and switch, because the insurance companies still rate the person, and if they have a pre-existing condition, the out-of-pocket and premiums go sky high."

The better solution, says Dr. Pomerance, would have also been much simpler. "I'm not usually in favor of more regulations, but all we really needed to do was require the insurance companies to issue insurance to everybody. What we're doing now is taking insurance away from somebody so somebody else can have it, and then we're requiring the people who gave it up to get it again."

Full transparency and patient responsibility would make the needed difference, says Narayanachar Murali, MD, FACP, FACG, of Gastroenterology Associates of Orangeburg (S.C.), adding that insurance "muddles" transparency. "The patient is shielded from the cost of care completely," he says. "That's why the care in this country is so unaffordable. And the ACA has made it unaffordable for everybody. The whole system is corrupt. Once you have the patient in charge of the decision-making, and not a third-party administrator, which is what is happening now, it will be OK."

A better model?
If there's some agreement that private insurance companies are at least part of the problem, there's no such clear consensus as to what the role of government — or the alternative solution — should be.

"Single payer," advocates Dr. Kotler. "Cut out the middleman. But don't count on such a practical and economical solution. Why would insurance companies give up their profitable business?"

Medicare is the model, says Dr. Kotler. The military, Mr. Purtle points out, uses the same model. "Nobody paid; everybody got taken care of," he says. "I don't know if that's the answer, but I think that's what's going to happen."

The law is still new. How it will ultimately unfold remains to be seen, but if anything is certain, it may be that the incessant shouting and finger-pointing going on in the political arena aren't helping to smooth out the rough edges.

"I don't know the answer," says Ms. Conilogue. "I just know that it's really frustrating at this point. There are places that are refusing care to people (with ACA-issued policies), and that's not the objective of the ACA. That's why things have to be changed over time. Everybody just has to be patient and do the best they can."