Healthcare in the age of the Affordable Care Act.
Ever since the Affordable Care Act (ACA) was passed and signed into law in March of 2010, pundits, journalists and the public in general have all speculated on what it would mean for the millions of Americans who would converge on the newly remodeled healthcare system. Would deductibles really be affordable? Would individuals be able to keep the same doctor? And would the flood of the newly covered make the act of seeing a doctor a tedious, all-day affair?
These questions have yet to be answered definitively, but now that the mandatory deadline has passed for individuals to enroll in a health insurance plan, perhaps it’s time to consider how another group will be impacted by the new regulations: the doctors themselves. Here, we look at just a few ways providers have altered the way they practice medicine in the face of the ACA.
Fewer private practices
The days of visiting a small, private office where only two or three physicians practice may soon be history if current speculations hold true. According to Dr. William Meade, Jr., MD, a practicing ER physician at Tri-City Medical Center in Oceanside, California, who also holds an MBA in health sector management, the current healthcare environment that gives patients less control in choosing their own doctor is making private practices increasingly unviable.
“As in any business, the value of the practice is based on the lifetime value of the customers, in this case, patients,” explains Meade. “A physician could plan for a solid exit from his practice after 20 to 30 years of hard work by selling his practice, and the value of that practice would be based on the patient base that would be exclusive to that physician. Currently, reform has shifted the health care model to population management through integrated networks of health care. In this model, there is less emphasis on the individual physician, but instead greater emphasis on the system as a whole. As a result, the physician is like an employee in a system controlled by the insurance companies and federal mandates. Fo r physicians in private practice the value of building a practice is diminishing, but the risk is increasing.”
Meade also notes that many private practices are consolidating in order to leverage market power for increased insurance reimbursements and that there is an additional trend of practices being sold to a hospital health care system, thereby making doctors employees of the larger group.
“This has its advantages from the physician standpoint, because doctors are allowed to practice without the burdens that come with running a business,” says Meade. “This trend has also affected the younger physicians after they complete residency. New doctors are now looking for employment opportunities where they can practice their specialty, immediately earn an income and not have to deal with the stresses of building a practice.”
Practicing in a bubble
Many of the medical advancements achieved in the last century can be largely attributed to the collaborative nature of healthcare, in the sense that doctors have been allowed to learn from the mistakes and successes of their peers. But that, too, may be changing.
“Security trumps communication, so, for instance, I cannot email consults to referring doctors because ‘the Internet is not secure’,” says Dr. Deane Waldman, MD, Emeritus Professor of Pediatrics, Pathology and Decision Science at the University of New Mexico. “Because the increasing regulation makes info-sharing harder and harder, doctors cannot learn by sharing adverse outcomes and can never aloud in public, much less to a patient, say, ‘I made an error; what can we learn from this?’”
In addition to restrictive privacy guidelines, Waldman, who authored the book The Cancer in Healthcare, says that hospital risk management departments, though well-meaning in their efforts to reduce liability, make healthcare less efficient and effective. “Over-regulation has been a fact and an increasing obstacle for a long time; HIPAA and PPAHCA have just made them worse,” says Waldman. “The problem is that the government offers guidelines, but then the hospital lawyers make extreme, stringent interpretations in their attempts to protect the hospital from liability, even though that often prevents clinical learning and improvement. For instance, they sequester records when something bad happens, instead of encouraging wide-open discussion so we can find the error, if present, and fix the system so it can’t happen again. Research itself is shackled by massive over-regulation and security restrictions.”
If greater access to affordable healthcare plans was the primary intent of the ACA, many individuals may be shocked to discover that access to actual healthcare may be hampered by doctors who have had to thoroughly reevaluate their billing and payment systems.
At the Connecticut Skin Institute, a small dermatology practice in Stamford, Connecticut, staffers are now forced to collect payment in full at the time of service – even from patients with coverage. “Our reimbursement rates with insurance providers already barely cover costs, and the exchange [also called the Health Insurance Marketplace] is making it worse,” says Dr. Omar Ibrahimi, MD, PhD, the clinic’s founding medical director. “We are in network with the exchange with two of the biggest insurance providers. However, our rates through the exchange are lower than those through individual or employer plans. Additionally, even though folks may have insurance through the exchange, their deductibles are so high that we end up having to chase payments from patients. We don’t want to have to take payment at the time of service because their medical needs are priority, but with the lower reimbursements and high deductible plans, we don’t see much of another choice.”
And, unfortunately, adds Ibrahimi, the circumstances at the Connecticut Skin Institute may not be unique. “I think this is being faced by most doctor practices, especially the solo practitioners,” she says. “More and more offices are requiring patients to pay their portions at time of service due to the increase in high deductible plans and, hence, the increase in bad debt. Patients come to the office thinking they are fully covered only because they have insurance, and some don’t realize that they have a deductible and get upset with the physician office for collecting, without realizing that they owe what they owe due to the plan they picked. It’s an unfortunate situation because healthcare premiums continue to go up, so some patients are forced to pick plans that have ridiculous deductibles.”
Tough days ahead
Change is never easy, especially when altering systems that have been in existence for many years. And while there is, perhaps, no way to really “fix” America’s healthcare system without disrupting the processes of some or all of the parties involved, the hope is that the challenges are worth it and that more Americans will have access to life-saving care.