Tag Archives: affordable care act

ACA: Helping or Hurting Solo Practice?

It won’t surprise many to learn that the age of the solo practitioner has, for the most part, come to an end. Over the past several years, small and solo practices have closed, been sold to hospitals, or merged with larger groups. The reasons are fairly obvious. Declining payments, rising malpractice costs, increasing regulatory burdens, costly new health information technology requirements, and crushing medical school debt have made it difficult for physicians to operate the small practices that once were commonplace around the country.

Now add the Affordable Care Act (ACA) to the mix. At a July 19 hearing of the House Small Business Subcommittee on Investigations, Oversight and Regulations, lawmakers questioned whether the health reform law would help or hurt physicians looking to keep their practices small and independent. The answers from the expert panel were mixed.

Gone are the days of Marcus Welby. Courtesy Wikimedia Commons/Public Domain License

The emergence of accountable care organizations (ACOs) will drive more hospitals to buy up small physician practices, Mark Smith, president of the physician recruiting firm Merritt Hawkins, predicted. The health reform law heavily promotes the formation of ACOs, which call for physicians and hospitals to work more closely and to share in bundled payments for episodes of care. Mr. Smith said small practices aren’t well-positioned to enter the ACO world if they aren’t integrated with a hospital because the ACO model calls on practices to assume financial risk.

But Joseph M. Yasso, Jr., DO, a family physician in Independence, Mo., who sold his practice to a hospital group 20 years ago, said the ACA’s promotion of patient-centered medical homes could be a lifeline for small practices. Physicians are adapting to the new environment by becoming medical homes and participating in government pilots where they can share in the savings they generate by providing more efficient care, he said.

One thing everyone on the panel did agree on was the need to fix the Sustainable Growth Rate (SGR) formula used in setting physician payments under Medicare. No surprises there either.

— Mary Ellen Schneider

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Louisiana’s Medicaid Nightmare

Physicians in Louisiana may find themselves holding the short end of the stick very soon, as the state struggles to figure out how to make up a sudden $859 million shortfall in Medicaid funding.

And it comes at a time when the state’s Republican governor, Bobby Jindal, has said that he will not take any additional federal money to expand the Medicaid program in 2014, as offered under the Affordable Care Act. He also said he would not accept federal funds to set up health insurance exchanges under the law.

Bobby Jindal. Courtesy Wikimedia Commons/dsb nola/Creative Commons Attribution 2.0 Generic License

If any hospital or physician wanted to know what it would feel like to go without that federal money, they now have their chance. The $859 million hole is the result of a reduction in the federal matching rate that Congress approved as part of the transportation bill that was signed by President Obama on July 6.

The provision affects only Louisiana. After Hurricanes Katrina and Rita, the state received hundreds of millions in aid. But there was no adjustment at that time in the federal Medicaid matching rate. So Louisiana’s Medicaid program was the recipient of millions of dollars more than what it was due. (For more on this byzantine situation, see the New Orleans Times-Picayune’s story here.)

Congress fixed that error in the transportation and student loan bill by dropping the state’s current match rate. But Gov. Jindal, in creating and finalizing his fiscal 2013 budget, was, ironically, depending on that federal money.

On July 13, his administration announced cuts to make up the shortfall. The decrease in the federal matching rate meant that the state had to come up with $287 million in cuts on its own; the rest of the $859 million will come from reductions in pay from the federal government.

According to the state Dept. of Health and Human Services, $518 million will come out of the pockets of physicians and hospitals.  The state already had announced an across-the-board almost 4% cut in Medicaid provider rates for fiscal 2013.

Under the latest cuts, the Louisiana State University system is taking the biggest hit: $329 million, or a quarter of its budget, according to news reports. LSU is one of the biggest charity care providers in the state. Interestingly, DHHS commented in its press release that it “does not anticipate this reduction of [disproportionate share hospitals] and Medicaid payments to affect Medicaid recipients’ access to hospital care.”

Among the other programs absorbing blows: the Greater New Orleans Community Health Connection (GNOCHC), a pilot that expanded health coverage to uninsured adults in the wake of Hurricane Katrina. Another program that provided family planning services to low-income women will have its qualifying income limit reduced from 200% to 133% of the Federal Poverty Level.

The state is also tightening its review of eligibility for all Medicaid recipients.

After the cuts were announced, the Louisiana Hospital Association said in a statement that, the total elimination of DSH payments to rural hospitals “will be critical and will lead to reductions in services and possible hospital closures.” That in turn will leave ” gaps in healthcare delivery for patients in rural areas, as well as economic losses to those communities,” said LHA.

With hospitals across the state possibly delivering less care, it seems likely that physicians could expect to see more pressure on their practices.

Alicia Ault

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Health Officials to Docs: Help Save ACA

Health officials are encouraging doctors who support the health law to help save it. By telling patients about how the Affordable Care Act will benefit them and the entire system, physicians can help garner support for the ACA, said Kathleen Sebelius, secretary of Health and Human Services.

“The notion that [you] are going to share factual information and have people share that information with friends and neighbors and patients on websites, in blogs, and church groups, and at [parent/teacher organization meetings], that’s really what makes a huge impact,” Ms. Sebelius said while addressing primary care and specialist physicians at the annual conference of Doctors for America. She added that doctors should not only spread the news, but become a part of the process as well.

“Your comments, certainly, about what is happening in rulemaking is helpful … but more than that is participating in some of the new models of care,” Ms. Sebelius said.

Many physicians are skeptical about the ACA according to some surveys. However, Doctors for America is among those who support of the law. It remains to be seen whether there’s enough agreement among doctors to make a difference.  What do you think? Tell us in the comments section.

—Frances Correa (@FMCReporting on Twitter)

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What if the Supreme Court Tosses Out the ACA?

Opponents of the Affordable Care Act are hoping that the Supreme Court will soon invalidate the law and put a permanent end to the federal government’s expanded role in health care. But one Capitol Hill watcher says the defeat of the ACA by the high court could lead to something conservatives would like even less – single-payer health care. Well, not anytime soon. But tossing out the law could help nudge things in that direction over time.

Norman J. Ornstein, Ph.D., an author and resident scholar at the American Enterprise Institute, said he could imagine a scenario where if the ACA were defeated, over time, Democrats would move to expand Medicare beyond the 65 and older crowd. Mr. Ornstein, who has a new book coming soon on the growing dysfunction in Washington, offered his two cents while speaking to a group of physicians at the Society of Hospital Medicine’s annual meeting in San Diego this week.

Protesters outside the Supreme Court in March. Photo by FRANCES CORREA/ IMNG Medical Media.

Another way that single-payer health care could become a reality is at the state level. Individual states might experiment with single payer-type programs along the lines of the Green Mountain Care program in Vermont, Mr. Ornstein said. Lawmakers in that state have enacted legislation allowing them to phase in a single-payer health care system over the next several years. But they have yet to hammer out details on how to pay for the program and it’s unclear how long it will take to move from the current framework of public and private insurance to a single-payer system.

– Mary Ellen Schneider

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It’s March Madness!

Yep, that’s a shameless bid to appear higher on Google search results, but it’s also a pretty good metaphor for what’s happening in Washington in advance of the Supreme Court oral arguments on the Affordable Care Act–due to be heard March 26, 27 and 28.  Although speculation about how the Justices may rule has been going on for months, the gambling has reached a fever pitch.

ALICIA AULT/IMNG Medical Media

Next week is to Court Watchers as the Final Four is to legions of NCAA Division 1 basketball fans: The brackets have been completed; it’s just a question now of who will come out on top.

Conventional wisdom has the Supreme Court splitting along perceived “party lines” in a 5-4 vote either in favor of upholding the law, or against it.

But with the Justices taking on three separate, major issues within the law, Washington wonks, soothsayers, and legal eagles have gone into a frenzy of handicapping. Not a day goes by without a backgrounder or briefing that professes to have the best read on the tea leaves.

The Court, as is its wont, has shied from the limelight. Until today, it had not even determined how it would accommodate the legions of journalists (myself included) who will descend upon the courtroom to cover the historic arguments. Details are still being worked out, but one thing was not going to change: the Court has steadfastly refused to allow audio or video broadcasts of the proceedings. (Which means there cannot be any contests requiring a shot every time the challengers’ attorney, Paul Clement, utters “individual mandate.”) The Court is even banning–heaven forbid–cellphones. That means no pithy Tweets on Justice Clarence Thomas’ enduring silence.

This morning–at a briefing sponsored by Politico–came new predictions from an estimable panel of D.C. insiders: former U.S. Solicitor General Walter DellingerNeal Katyal, Al Gore’s co-counsel at the Court in Bush v. Gore,  Tom Goldstein, a former Court clerk and publisher of Scotusblog, Kevin Walsh, a former clerk to Justice Antonin Scalia, and Nina Totenberg, the veteran Court correspondent for NPR.

Dellinger, Goldstein and Katyal. ALICIA AULT/IMNG Medical Media

The Justices to watch, said Ms. Totenberg: Anthony Kennedy and Chief Justice John Roberts. They are both widely considered swing votes. Some have also have put Justice Scalia in that camp, “which I personally think is a crock,” Ms. Totenberg said. Mr. Katyal said that Samuel Alito could also be “in play.”

Will politics come into play? Justices “have a grasp of politics that defies imagination in terms of its inaccuracy,” said Ms. Totenberg, who, like the others discounted the idea that the Justices would be influenced–or motivated–to vote in one direction or another based on the prevailing political winds.

The panel was unanimous–except for Ms. Totenberg, who recused herself from making a wager–in its opinion that the Court would uphold the law, most likely in its entirety.

Mr.  Goldstein said he could not effectively imagine a victory by the law’s challengers. If the Justices threw out the Act, it “would lead to probably an array of attacks on different parts of the federal regulatory state because for the first time you would have had five justices that take very seriously limits on congressional power,” he said.

By the end of next week, the Court will likely hold one closed-door conference and a series of votes, said Mr. Walsh.

He and the other panelists went out on a limb, saying that the 5-4 prediction may no longer hold.  Mr. Goldstein said it could even be a 6-3 or 7-2 ruling upholding the law.

So who will write the opinion, expected to be issued in June? Mr. Dellinger predicted that it would be Justice Roberts. Mr. Goldstein, however, said this might be the rare case where the Court issues a per curiam opinionthat is, written in the name of the Court, rather than by any of the Justices. Interestingly, Bush v. Gore was a per curiam decision.

What is your opinion?

Alicia Ault

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Getting Ready for the Insurance Exchanges

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy.

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

— Mary Ellen Schneider

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A Younger Kennedy’s Mental Health Crusade

Patrick J. Kennedy is no longer in Congress, but he’s still campaigning passionately on behalf of mental health. In a plenary talk at the annual meeting of the American Association for Geriatric Psychiatry (AAGP), the former democratic congressman from Rhode Island described his recent mission: An organization he founded called One Mind for Research, which “brings together the science, technology, financial resources, and knowledge required to create an unprecedented understanding of brain disease.” Its goal is to increase the investment in research by $1.5 billion each year for the next 10 years and to achieve a minimum 10% reduction in the cost of brain disease per year.

Courtesy of AAGP

The initiative was launched last May 25th on the anniversary of his uncle John F. Kennedy’s “Moonshot” speech, at the suggestion of his cousin Caroline. He said he told her at the time, “Great, instead of going to outer space, we’ll go to inner space!”

On a more serious note, Mr. Kennedy drew a parallel between President Kennedy’s focus on civil rights as a moral issue and the cause of the mentally ill, telling the audience of psychiatrists “What you all do in the field of mental health is to help lessen the marginalization of too many Americans…I think we have a historic opportunity now, with the implementation of the Mental Health Parity Bill and the [Affordable Care Act] to break down the segregation of mental health from overall health.”

Referencing his own struggles with substance abuse, depression and bipolar disorder and his role in Congress as chief sponsor of the parity bill, Mr. Kennedy decried the current insurance reimbursement system as being “wholly inadequate” for treating chronic mental conditions. “If we treated diabetics the way we treat alcoholics and addicts, we’d be waiting till we were cutting off their toes and they’d lost their eyesight before we paid for treatment,” he said, to applause.

He was equally emphatic regarding the politics involved in securing funding for One Mind’s 10-year plan. “If you consider how much money we put into neuroscience today compared to the burden of [mental] illness, any CEO in the country would be kicked out of their job for not doing enough research…it just doesn’t compute,” he said, again to applause.

He acknowledged there would be challenges. “I can’t tell you we’re going to be successful, but at least I’m going to do my part to see that we try something different.”

The AAGP plenary session was supported in part by an educational grant from Lilly USA, LLC.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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