Healthcare reform moves forward, but where do you stand?
By Joy Daughtery Dickinson, Executive Editor
Brace for millions of more patients. With the recent Supreme Court ruling that cleared a path for most provisions of the Patient Protection and Affordable Care Act (PPACA) to proceed, you might see a measurable increase in surgery patients as early as next year and continuing through the end of the decade, predicts the Association of periOperative Registered Nurses (AORN).1
However, as one news report from Associated Press explained, "it's not a slam dunk."2
Rich Umbdenstock, president and CEO of the American Hospital Association, said in a released statement "... [T]ransforming the delivery of health care will take much more than the strike of a gavel or stroke of a pen. It calls for the entire healthcare community to continue to work together, along with patients and purchasers, to implement better coordinated, high-quality care."
The ruling is expected to transform the healthcare insurance market, which will affect outpatient surgery for years to come, the Ambulatory Surgery Center Association (ASCA) predicts.3 Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, executive director/CEO of AORN, says that with 27 million newly insured people predicted by 2016, "that means they'll have access to primary care, which then has a potential impact on ORs and number of people having elective surgery that put it off because they didn't have health coverage."
Bill Prentice, CEO of the ASCA, agrees. "If more people have health insurance and use it, I think clearly that would bring more patients to the front doors of physicians, ASCs, and hospitals, rather than people putting off care they should be getting taken care of, but can't afford to," Prentice says. "I hope if they have coverage, they can get the care they need."
Because hospital ORs can handle only a set amount of surgery, more surgery will be driven to freestanding centers, Groah predicts.
One bonus for outpatient surgery providers: The Supreme Court upheld the waiving of deductibles and copays for colorectal cancer screenings. "This provision may incentivize more patients to have a colorectal cancer screening...," according to the ASCA.3 An oversight in the current law requires Medicare beneficiaries to cover the cost of their co-payment for a "free" screening colonoscopy if a polyp is discovered during the procedure. The "Removing Barriers to Colorectal Cancer Screening Act of 2012," currently before Congress, would waive coinsurance for colorectal cancer screening tests, thus covering 100% of their cost under Medicare part B.
With the changes coming, hospitals are likely to have added interest in outpatient care, Groah says. However, that interest might not necessarily translate to building additional facilities, she says. "But they may take some existing facilities, for example, they may remodel or look at whether they can incorporate a portion of the inpatient surgeries' space and use as ambulatory surgery centers," Groah says. "For example, if they have 10 ORs, they might take two or three and make them into a small section for ambulatory surgery."
With the increase in patients, it will be important for perioperative nurses to continue their educations so that they are well-trained, AORN has said. The Supreme Court decision sustained funds for nurse education, quality, and retention, the association said.
Increased consolidation in the marketplace
The Supreme Court decision allows the Medicare Accountable Care Organization (ACO) program to continue.
"ACOs are in the process of forming, and their impact on ASCs remains to be determined," the ASCA said.3
Prentice says, "The potential for increased consolidation in the healthcare marketplace concerns us. It should concern everyone."
The accountable care organizations, which are being established to try to create networks to coordinate care of Medicare patients, "sounds like a good thing" he says, "but there are serious concerns about healthcare consolidation in certain markets. You've got one health system controlling the patient base in that marketplace and choosing who can participate in that system. If they wanted to freeze out certain physicians or delivery models, like ASCs, there's that potential."
In some marketplace, hospitals and health systems are buying up primary physician practices, Prentice says. "That should be a concern to those who view free market positively and the innovation that come with competition in marketplace," he says.
Coordinated care arrangement should include surgery centers, due to their cost savings and patient convenience, he maintains. (For more information on the impact of the Supreme Court ruling, see stories, below.)
- Association of periOperative Registered Nurses. AORN/Advocacy/Public Policy News. Health Care Reform Decision. July 2, 2012. Accessed at http://bit.ly/OcVqXH.
- Johnson A. High court ruling benefits most health care firms. June 28, 2012. Accessed at http://apne.ws/NDxD2D.
- Ambulatory Surgery Center Association. How the Supreme Court's ruling on health care affects ASCs. Government Affairs Update. June 28, 2012.
The entire Supreme Court opinion is available at http://bit.ly/M8yRq6.
Brace for less money, more emphasis on quality
With the Supreme Court clearing the way for about 27 million new covered patients under the Patient Protection and Affordable Care Act (PPACA), about half of the patient newly covered by a payer will be Medicaid patients, according to a report from the Associated Press (AP).1
Medicaid patients equal less reimbursement than cost, the AP story points out. In addition, Medicare payment increases will be less under the law, AP says. The reason is the Independent Payment Advisory Board (IPAB), which will reduce Medicare's costs beginning in 2014 by recommending specific Medicare reductions, the ASCA says.2
"Because certain providers such as hospitals are exempt from the cuts until 2018, and because benefits cannot be targeted for cuts, the IPAB would, by necessity, have to target ASCs, physicians, drug manufacturers and nursing homes for reductions in order to meet their targets," according to the Ambulatory Surgery Center Association (ASCA).
That's a worry, says Bill Prentice, CEO of the ASCA. "We have real concerns, as do many physician groups, with the independent payment advisory board," he says. "We're concerned about that being a 'black box,' leading to cuts that don't make sense."
Brace yourselves, say outpatient surgery leaders, including Bobby Hillert, executive director of the Texas Ambulatory Surgery Center Society. "The IPAB and state-based health insurance exchanges that could result in narrow provider networks to keep costs low are among the issues that could have a dramatic impact on both the Medicare and commercial insurance markets," Hillert says. [Editor's note: On June 9, we sent an email bulletin about new Medicare proposed payment rates for ASCs and hospital outpatient departments. If you didn't receive the bulletin, we don't have your email address. Contact customer service at firstname.lastname@example.org or (800) 688-2421. Also, receive breaking news by following us on Twitter @SameDaySurgery.]
The Centers for Medicare and Medicaid Innovation (CMMI) created by the ACA will continue to look for innovative payment and delivery system models to cut Medicare and Medicaid costs, the ASCA says. "ASCA has been working with CMMI and evaluating the possibility of establishing a pilot to pay ASCs for performing total joint procedures on Medicare beneficiaries," the ASCA says.2
Prentice says, "We're interested in using the program to show ASCs can save money if we could do more complicated procedure than Medicare currently allows us to provide to beneficiaries."
Although the impact of the health insurance exchanges to be set up in each state is unknown, reimbursement rates should be better than the bad debt that is generated now by the uninsured, says David A. DeSimone, Esquire, vice president and general counsel at AtlantiCare Health System, Egg Harbor Township, NJ, and co-chair of the ACO Task Force of the American Health Lawyers Association.
Consider these other impacts:
• Requirements to offer health benefits to your workforce.
With all the good news, there is an area of the ACA that provides pause, DeSimone says.
"One caveat for small businesses like surgery centers and surgery practices is the requirement to offer health benefits to their own workforce for the first time with the individual mandate in 2014," DeSimone says. "There is hope that the insurance exchanges will provide market forces to keep health benefit costs competitive and preventive care will help make workers healthier and thus more productive, but it also could fuel further healthcare integration as providers, including surgery centers and surgeons, seek to share overheads costs such as benefits in large groups or networks."
• Increased emphasis on quality.
Government and private insurers are predicted to demand improved outcomes, the AP said.1 Healthcare providers will be forced to make improvements such as electronic health records, which are expensive, it points out.
Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, executive director/CEO of AORN, says, "Quality is always important. With the ACA, there is even more emphasis on it."
Value-based purchasing includes not just quality and performance improvement, but also patient satisfaction, she says, "and that's a part of what the DRG payment and outcomes measures will be all about."
Perioperative nurses and others are working toward zero adverse events, such as surgical site infection and retained foreign objects "that don't represent the best quality we can provide to our patients," Groah says.
Physician-owned hospitals still under restrictions
The recent Supreme Court ruling to uphold most of the Patient Protection and Affordable Care Act (PPACA) left physician-owned hospitals still under what has been described by their association as "onerous restrictions."
"Despite the fact that these are some of the very best hospitals in the country, PPACA unilaterally banned any new hospitals owned by or in partnership with physicians from seeing Medicare and Medicaid patients.," said John Richardson, executive director of Physician Hospitals of America.
While there was a grandfathering exemption for existing physician-owned hospitals, even those hospitals can't add new beds or operating rooms, Richardson points out.
"The law also prevented a limited number of hospitals with physician ownership, which were still under construction, from receiving their license to treat Medicare and Medicaid patients," he says.
The Physician Hospitals of America is strongly encouraging repeal of the act "so that Congress can consider the types of reforms that the American people are longing for — reforms that ensure patients have access to high quality care when they need it," Richardson says.
Support has come from what some might see as an unexpected ally: a state ambulatory surgery center association. Bobby Hillert, executive director of the Texas Ambulatory Surgery Center Society, says, "As a state society, we support physician ownership in not only ASCs but other facilities, such as hospitals, and ancillary services, such as imaging. Federal laws have allowed physician in a number of areas over the years because it results in better quality and convenience for patients."