Thanks to the Supreme Court ruling and Barack Obama's re-election, the Affordable Care Act isn't going away. The issue now is how it will work.

Even by Washington standards, implementing this law is extraordinarily complex. The federal government last year issued 70,000 pages of guidance, including 130 pages on the look of websites for new marketplaces where many will shop for insurance.

Here’s a quick look at how it will impact consumers, employers, states, and health care providers.

What will consumers do?

Most will do pretty much what they do now. About 55% of Americans of all ages get health insurance through an employer; another 32% through a government program. For most, not much will change, though workers are likely to pay more for health care as employers pass along costs. Also, the law will require employers who offer skimpy benefits to provide more robust ones.

The challenge is to prompt one group of consumers to change—the 18 million 20- and 30-somethings who don't have health insurance. The arithmetic of Obamacare depends on getting more Americans to buy health insurance. If the young and healthy don't show up, the math doesn't work—and the cost of insurance for those who do shop in the new exchanges will be higher.

What will employers do?

Mostly wait and see. Even employers flirting with getting out of the benefits business or giving workers a fixed sum and letting them shop for insurance won't move quickly.

Implementing the Affordable Care Act is extraordinarily complex. One provision already appears to be having unwelcome, unintended consequences. It requires employers with more than 50 workers to offer insurance to anyone who works 30 hours a week or more. That gives fast-food, retail and other employers who rely heavily on low-wage, part-timers an incentive to keep workers to 29 hours or less; word is that many already are doing so. Smaller firms have reason not to expand their workforces above 50, or to game the system by subdividing themselves.

The Congressional Budget Office estimates that about 8 million fewer workers, about 5% of the total, will get insurance through employers five years from now than would have been the case without the Affordable Care Act.

But no one really knows how many employers will find ways to drop coverage or to structure benefits so sicker, costlier workers get insurance at the new exchanges.

What will states do?

 

They have until Friday to decide whether to create an exchange or let the federal government set one up. New York and California already are committed to fully running their own exchanges; Texas and Georgia have signaled they won't take on any of the tasks. It isn't clear how much help the abstainers will offer Washington in crafting the marketplaces and recruiting customers. State resistance would be an obstacle to an already tough task.

And then there is Medicaid, the state-federal program for the poor. The law substantially expands eligibility, at Washington's expense for the first three years, but the Supreme Court ruled that states don't have to go along. CBO projects that in the next five years, Medicaid rolls will grow to 45 million from 36 million.

About half of the governors (including six of the 29 who are Republican) have decided to expand their Medicaid programs; turning down federal money is hard.

But about half say they won't (including 13 Republicans) or are still on the fence (including 11 Republicans). States that don't expand Medicaid likely will have more uninsured, which means, among other things, that health-care providers and employers who do offer insurance will, effectively, pick up the cost of caring for the uninsured when they do get care.

What will health care providers do?

Merge and grow bigger. The law encourages the integration of hospitals, doctors, and nursing homes. It takes aim at the underlying problem: The U.S. has evolved the developed world's most inefficient health-care delivery system, one that too often rewards volume of care and not quality. Integrated health providers such as Kaiser Permanente and Geisinger Health System are seen as models of low costs and high quality.

But there is a risk or—if you talk to insurers—a nightmare. The proliferation of hospital mergers and hospitals' appetite for buying doctors' practices—in part to assure a steady stream of patients to fill hospital beds—could create local monopolies that raise prices without increasing efficiency.

Source: The Wall Street Journal, February 13, 2013.

By Toni Brayer, MD

One of my tennis friends asked me about new innovative smart phone technology and why it hasn't been embraced in health care. She had just watched a video about Dr. Eric Topol, Chief Academic Officer at Scripps Health in San Diego, and his demonstrations of how a smart phone could monitor blood sugar, take EKGs and cardiac ultrasounds, and really deliver health care to the patient at home. 

My friend's question, "If this technology is here, why isn't it being used?"

According to Dr. Topol, new apps for the smart phones could eliminate 80% of echocardiograms that are done in facilities at costs between $300 and $1500 each. Having patients come into the office when they experience symptoms or for diabetics to get their blood sugar regulated could be eliminated. New technology could be data driven and personalized and save millions of wasted dollars in health care. So why is medicine so far behind the innovation curve?

The answer: No-one pays for it. 

Why aren't all physicians using email to communicate with patients and save them an office visit? The  politically correct answer is "remote medicine is not as good as seeing the patient in person and making sure the diagnosis is correct". The real answer is: No-one pays for it.

United States health care has complicated payment systems for work done. The payor for health care services is either Medicare/Medicaid (CMS) or hundreds of different (for-profit) insurance companies.  CMS sets the payment rules that everyone follows. Medicare and all insurers will only pay for face to face visits. Reimbursement is for doing more and the more you do the more you get.

The doctor that tries to save a patient time and travel by covering a number of problems in one office visit will not be rewarded and, in fact, will be reimbursed less. If you do a skin biopsy on the same day you do a visit for arthritis flare, CMS and insurance companies will not pay for both things. Do them on separate face to face visit days and... voila!... a better reimbursement for your time and skill.

Email, remote monitoring, remote echocardiograms, discussing tests via a smart phone are freebies. No patient visit means no reimbursement. The cost of putting in high technology is borne by the physician too.

Most physicians and hospitals and surgery centers and labs and pharmacies are happy with this status quo. There is great fear of change and so we continue to spend more on health care than any nation in the world. We do wasteful mass screenings and 1/3 of all prescriptions are a waste. People who need care are not getting it and others are getting too much that they don't need.

ObamaCare is trying to make some gradual changes by supporting pilot programs to change the way healthcare is delivered. But it is slow going and innovative answers are out there. If we could just figure out how to pay for services, while using new cost-saving technology we would all be following Dr. Topol's future dream.

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Originally published in EverythingHealth, February 10, 2013.

Toni Brayer, MD is an internist and Chief Medical Officer for Sutter Health West Bay Region. A SFMS member since 1987, Dr. Brayer has served as President, CMA delegate, Editor of San Francisco Medicine, and on numerous committees over the years. She is a Fellow of the American College of Physicians and an Assistant Clinical Professor at UCSF. Dr. Brayer blogs at EverythingHealth.net.

CMS announced the long-awaited final rule on the Physician Payments Sunshine Act last Friday, which will raise public awareness of the financial relationships between medical device and pharmaceutical companies and doctors and teaching hospitals.

The Sunshine Act—established under the Affordable Care Act—requires medical industry companies to disclose all transfers of monetary value over $10 to physicians and teaching hospitals.

Under the final rule, manufacturers of pharmaceutical and biological drugs, medical devices and medical supplies—covered by Medicare, Medicaid and CHIP—starting August 1 will be expected to report all consulting fees, travel reimbursements, research grants and other gifts with values over $10 that they give to physicians and teaching hospitals. In addition, the manufacturers and group purchasing organizations will be responsible for reporting physician ownership and investment interests.

CMS set the August 1 start-date for data collection to give the affected entities time to prepare, officials said. All data collected from August through December must be reported to CMS by March 31, 2014, according to the rule. The agency will publish the data on a public website by September 30, 2014, one year later than the date originally set in the ACA.

Physicians will be given a 45-day "review and correction" period to ensure the accuracy of any disclosures to CMS, according to the final rule. The rule also notes that the Sunshine Act overrides similar state laws, creating the possibility of "cost-savings, since a single reporting system for reporting this information is less burdensome than multiple programs".

The final rule is scheduled for publication in the Federal Register at the end of this week.

Source: California Healthline, February 4, 2013.

This morning, the California Medical Association (CMA) filed a request for an en banc review by the Ninth Circuit Court of Appeals to stop the State of California from implementing a 10% cut to Medi-Cal provider reimbursement rates. Last month, a three judge panel of the Ninth Circuit ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. CMA and the other plaintiffs in the case are now requesting a rehearing from the full Ninth Circuit Court of Appeals.

Following the reversal, Governor Jerry Brown issued his 2013-2014 budget proposal, which includes a 10% Medi-Cal reimbursement cut, retroactive to January 1, 2013.

CMA and the other plaintiffs in CMA et al. v. Douglas et al. – California Hospital Association, California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response – argue that reducing payments in the Medi-Cal system will force providers out of the program at a time when millions of new patients will be diverted into the Medi-Cal system.

If the state moves forward with these cuts, access to care will be devastated, not only for the existing Medi-Cal patients, but also the 900,000 kids moving from the Healthy Families program into Medi-Cal in 2013 and the millions of patients that will be newly eligible for Medi-Cal under the Affordable Care Act in 2014.

“Cutting payment to Medi-Cal providers by 10 percent will have a huge impact on patient access to care,” said Paul R. Phinney, MD, CMA president. “The state is in much better fiscal shape now than when these cuts were initially proposed in 2011 and with millions of new Medi-Cal patients entering the program under the Affordable Care Act, we simply cannot continue to cut resources and expect successful implementation of health reform in California.”

The lawsuit to prevent the cuts was originally filed by CMA in November 2011.

By Toni Brayer, MD

Medical training programs should take notice of a new study that was published in Mayo Clinic Proceedings. It listed the top ten reasons why people see a doctor. Keep in mind these were people who lived in Rochester and Olmsted County, Minnesota, but I suspect the conditions are not too different across the United States. As I review the main reasons patients visit me, it seems like they got the list right. Here are the conditions that  bring people to visit the doctor:

• Skin disorders
• Osteoarthritis and joint pain
• Back problems
• Cholesterol problems
• Upper respiratory conditions (not including asthma)
• Anxiety, depression and bipolar disorder
• Chronic neurologic problems
• High blood pressure
• Headaches and migraines
• Diabetes

They found that most of these chronic, non-acute problems were not age or gender related. Half of the study population had a skin disorder like acne, cysts or dermatitis. Among children and teens the main problems were skin, joint problems and upper respiratory conditions. Patients over 65 showed up with high blood pressure, cholesterol problems and ...again skin disorders.

All of these problems should be handled in a primary care office. With the shortage of primary care doctors, however, we can expect health care expenditures to continue rising if these common problems are taken to specialists. In my community it is difficult to find dermatologists who will see "skin disorders" and most do not accept any insurance. They are happy to deal with cosmetic dermatology and biopsies but not routine dermatologic conditions.

Most orthopedic specialists are not interested in dealing with osteoarthritis, back pain or joint problems that do not require surgery or arthroscopy. 

With less than 2% of medical students expressing an interest in primary care medicine it will be interesting to see where the bulk of patients will be getting their care in the future.

Source: EverythingHealth, January 23, 2013.

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Toni Brayer, MD is a SFMS member and a past president. She currently serves on the San Francisco Medicine Editorial Board, and is the Vice President and Chief Medical Officer for Sutter Health West Bay Region.