Health Reform to Stay the Bumpy Course


Posted by: Joel Wittman

As this is my first post since the presidential election, I thought that this would be a good time to look at how the ACA may play out.  Fierce Healthcare published an article about this soon after the election.  I thought it would be of interest to you.

Reelected for a second term, President Barack Obama is expected to carry out the landmark Affordable Care Act of 2010–but not without some resistance from a split Congress.

Many health reform provisions that hung in the balance during election season could see implementation in 2013 and 2014. The Democratic presidential win particularly confirms the forth-coming health insurance exchanges, the phasing out of annual insurance limits and protections for those with pre-existing conditions. However, it also leaves certain controversial provisions–namely, Medicaid expansion and the Independent Payment Advisory Board–in the hands of a divided Congress that may slow reform.

According to the Healthcare.gov timeline, the healthcare industry can expect:

Higher Medicaid payments for primary care physicians – Jan. 1, 2013
Under the Affordable Care Act, primary care physicians can expect Medicaid payments that resemble reimbursements for Medicare. Family doctors, internists and pediatricians next year will see Medicaid payments increase by up to 7 percent, estimated at $11 billion, although specialists have complained they are largely left out of the increased payments.

Medicaid expansion – Jan. 1, 2014
Perhaps one the most contentious issues that could see continued partisan politics is Medicaid expansion. Individuals who earn less than 133 percent of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. Although the Obama administration envisioned Medicaid expansion would be implemented across the country, the U.S. Supreme Court decision in June left it up to the states. Red, Southern states, in particular, have been particularly resistant to Medicaid expansion.

“The surprise Medicaid ruling by the Supreme Court will put hospitals in direct conflict with Republican governors who may want to not participate in the Medicaid expansion for political reasons,” Kent Bottles , senior fellow at the Thomas Jefferson University School of Population Health in Philadelphia and FierceHealthcare editorial advisory board member, told FierceHealthcare in an interview. “States not participating will be terrible for hospitals that are depending on the increased coverage to offset the decreased revenue from the federal government contained in the PPACA,” Bottles said.

With an expected 16 million uninsured Americans to enter the Medicaid system, provider reactions have been mixed, with some saying greater coverage for all will be a welcome relief, while others worry the patient volume will tax already overburdened staffs and resources.

“The ACA will increase the number of Medicaid beneficiaries, but it does not guarantee access to primary care,” Jesse Pines, director of the Center for Health Care Quality and associate professor of emergency medicine and health policy at George Washington University in Washington, D.C., told FierceHealthcare. Pines, a FierceHealthcare editorial advisory board member, noted many primary care physicians are turning away Medicaid patients, opting for higher-yielding patients who have commercial insurance or are on Medicare. “So it may be difficult for people to get in to see primary care doctors. With no other option (but with insurance), many will come to the ED,” he said.

Jeremy Tucker, medical director of the emergency department at MedStar St. Mary’s Hospital in Leonardtown, Md., and FierceHealthcare advisory board member, added his area already has physician shortages that may push newly insured patients to turn to emergency departments and urgent care centers to get their care.

“We are already seeing tertiary care hospitals that we transfer patients to asking us insurance status questions, and while they do not refuse to accept the patient, they will absolutely limit what they do for the patient [by simply stabilizing and discharging].”

He also said the physician shortage, coupled with increased patient volume, will lend to a higher reliance on non-physician providers, such as nurse practitioners and physician assistants.

Divided Congress could slow reform
With the Democratic hold on the Senate and Republicans maintaining the House, Congress will look much like the past four years–a political landscape that worries some in the industry.

“We should see more of the same–stalemates and gridlock in Washington,” Tucker told FierceHealthcare when asked the possibility of a Republican repeal.

A bitterly divided Congress could mean delays in appropriating money to fund the health law’s provisions.

The American Medical Association, while congratulating the President, also took the opportunity to point to the lingering question about the ever-present fiscal cliff–what will happen with the doc fix?

“The AMA is … committed to working with Congress and the administration to stop the nearly 27 percent cut scheduled to hit physicians who care for Medicare patients on Jan. 1, [2013],” AMA President Jeremy Lazarus said in a Wednesday statement. “It is time to transition to a plan that will move Medicare away from this broken physician payment system and toward a Medicare program that rewards physicians for providing well-coordinated, efficient, high-quality patient care while reducing healthcare costs.”

What are your thoughts about the ultimate success of the health care reform act?  Can a split Congress put aside their partisanship for the betterment of those in need of health care services who otherwise could not afford coverage?  While not perfect, the ACA is at least a start in the right direction.  Your comments are always welcome – let me hear from you.

Joel Wittman is an Adjunct Associate Professor at the Wagner School of Public Service of New York University.  He is the proprietor of both Health Care Mergers and Acquisitions and The Wittman Group, two organizations that provide management advisory services to companies in the post-acute health care industry. He can be reached at joel.wittman@verizon.net.

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