Health Care Reform Update

What Health Care Reform Means to You

Increased provider access tops list of what clinicians will like about HC bill

Changes will take a few years

Health care clinicians and organizations likely will find that the new health care reform bill's positive features outweigh its drawbacks, experts say.

The Patient Protection and Affordable Health Care Act, signed into law on March 23, 2010, by President Barack Obama, provides a series of changes to take place to health care insurance coverage, Medicare, Medicaid, prescription drugs, quality improvement initiatives, medical malpractice, and other items. These are to be implemented from 2010 to 2014.

"The thing that is so big is the coverage for tens of millions of people who don't have health insurance now," says Cecil Wilson, MD, an internist in Winter Park, FL, and the president-elect of the American Medical Association in Chicago, IL.

People no longer will have to worry about losing health care coverage for existing diseases if they lose their jobs, and increasing numbers of people will have access to preventive care, primary care, and disease management, Wilson adds.

"Those are the big things that make this such a sea change in my opinion," he says. "For physicians, this is good because they won't have to worry about their patients' insurance being cut off, and thus putting their patients at risk."

Hospitals will find that significantly more patients will have health care coverage, resulting in a decline in uncompensated care, says Caroline Steinberg, vice president for trends analysis for the American Hospital Association of Washington, DC.

"We also would expect that demand for care from formerly uninsured patients will increase," Steinberg says. "Hopefully, we'll see some increases in primary care so by the time they hit the hospital they won't have some of the same kinds of problems they've had before."

The new bill provides billions of dollars in funding for clinics that provide primary care to uninsured, indigent, and immigrant patients. In 2014, it also expands Medicaid to all non-Medicare eligible individuals who have incomes up to 133% of the federal poverty level. These initiatives could help send more people to primary care services and keep them from using the emergency room for non-emergency care, Steinberg adds.

"We may [identify] more people with conditions that require specialty care because once people have access to coverage they tend to use more health care across all levels of the system," Steinberg says. "So that could go either way."

Plus, hospitals should expect the next few years to continue to be rough fiscally since most of the more significant provisions in the bill will not be fully implemented until 2014.

"Our hospitals are telling us that uncompensated care is going up because of job losses and loss of insurance, and these people show up in hospitals," Steinberg says.

There won't be much improvement in the immediate future until the economy recovers and the government provides more funding for Medicaid, she notes.

More oncology patients will have access to care, as a result of the bill's prohibition of lifetime limits on the dollar value of coverage, which begins Jan. 1, 2014. There is a temporary national high-risk pool to provide health care coverage to people with pre-existing medical conditions, which will be in place between June 2010 and 2014.

"Many cancer patients who need repeated courses of treatment can easily exceed their caps and find themselves unable to afford needed treatment and medication," says Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO), in a statement issued after the bill was signed.

By this fall, insurers will not be able to exclude children with pre-existing conditions from being covered by their family policy, and this also is a positive move, Lichter says.

The bill's focus on prevention and wellness will benefit infectious disease and public health initiatives.

"There are a few things in the bill that we're pleased to see stay in the final version," says Michael Ochs, government relations associate with the Infectious Diseases Society of America (IDSA) in Arlington, VA.

The bill's emphasis on wellness and disease prevention with billions of additional federal dollars for these is one example, Ochs says.

The bill's impact on physician and other provider payments is a more mixed bag, however. (See story on physician payments, below.)

"There's a 10% incentive pay for primary care and general surgery," says Jason A. Scull, program officer for clinical affairs at IDSA.

"They're focusing on primary care in a lot of these new innovative payment models, but I think primary care does need to be incentivized," Scull says.

But the drawback is that cognitive specialists, like infectious disease specialists, cardiologists, and neurologists, could be shortchanged as the pie is cut differently, but not expanded.

"There will be unintended consequences," Scull notes. "Already last year the Centers for Medicare & Medicaid Services [CMS] eliminated payments for consultation codes that cognitive specialties use to give them money to distribute elsewhere in the fee schedule and to send more to primary care physicians."

This redistribution of payments might result in fewer medical students choosing to spend extra years of training beyond their general internal medicine residency, he adds.

While the sweeping health care reform provides some specifics on how changes will occur in the industry, no one knows precisely how things will change until the regulatory details emerge, the experts say.

"There are a lot of moving pieces to this," Scull says. "I think it's anybody's guess to where all of this ends up."

Doctors will be more closely scrutinized with bill's provisions

Experts talk about bill's negatives

Pay attention to the new health care bill's regulatory details, experts warn providers.

There are some items in the sweeping legislation that could result in more documentation, work, and risk for physicians and other providers.

For instance, the new bill makes it clear that the government wants doctors to be doctors and not own hospitals, says LaDale K. George, JD, a partner with Neal, Gerber, Eisenberg in Chicago, IL.

The bill puts a moratorium on any physician-owned hospitals in non-rural settings that were not Medicare providers as of December 2010.

"The new law says that the practice of physicians owning hospitals no longer is allowed," he explains. "If a physician owns or has a financial interest in a hospital and refers patients to that hospital then every service the patient receives at the hospital is a Stark violation of $25,000 per incident."

Also, the anti-kickback law has been changed by the new bill.

"The way the new act changes it is that it appears to eliminate the need to have actual knowledge or specific intent to violate the statute," George says. "It moves in the direction of where the Stark law is where if you do not meet the safe harbors in which providers can refer to one another and engage in commercial practices together then you will be viewed as being guilty."

From physicians' perspectives, some of the other requirements will be more onerous, particularly as far as documentation and accounting are concerned.

For instance, the bill's Physician Payment Sunshine Provision requires physicians to disclose every payment they receive from pharmaceutical and biotech companies in excess of $100, and this includes drug samples. This could prove to be an accounting problem for physician investigators and others.

This likely will be a headache to physicians, who will have to keep track of every sample they receive and every payment that flows through to them for research, George says.

The new health care bill also appears to give physicians incentives and/or penalties depending on their compliance with reporting data as part of the physician quality reporting initiative (PQRI), which was established with the 2006 Tax Relief and Health Care Act.

"What's clear is that Congress is moving into the direction of mandating physicians to participate in PQRI and also moving in the direction of mandating physician resource use reporting," says Jason A. Scull, program officer for clinical affairs at the Infectious Diseases Society of America.

"These are somehow merged into a value modifier that also will adjust payment based on the quality of care they provide," Scull says.

About one of six eligible physicians now makes the reports, and about half of these receive incentive payments, he adds.