Beyond the heated rhetoric, however, what will the complicated and fast-evolving elements of the ACA actually mean for rheumatologists, and for access, affordability, capacity, and delivery? In the short term, analysts say so much change is happening all at once that it’s nearly impossible to predict how it might turn out. “Everyone’s kind of holding their breath to see what happens,” says Ann O’Malley, MD, a senior fellow at the Washington, D.C.–based Center for Studying Health System Change.
Even so, experts are already seeing the signs of major trends. In the short term, one emerging theme is considerable geographical variation in consumer access and costs and in pressure on providers. “How this is going to feel will depend, to a great extent, on where you live,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.
Analysts also have seen hints of more universal changes, including an accelerated trend toward the consolidation of provider groups, an added emphasis on team-based care, and significant momentum towards a pay-for-performance delivery model.
For rheumatology patients, the biggest upside to the ACA is its expanded coverage, says Timothy Laing, MD, a rheumatologist and the associate chair for clinical programs for the department of internal medicine at the University of Michigan in Ann Arbor. That coverage, of course, isn’t sufficient for actual access, but it is necessary. “You can’t take care of somebody if they can’t get in the door,” he says. “That’s the big thing.”
Because rheumatologists take care of so many patients with chronic conditions, Dr. Laing says, two other aspects of the ACA are particularly relevant to the subspecialty. The new law, he says, bans insurers from excluding patients due to preexisting conditions or from capping lifetime coverage. “To have a fair approximation of coverage that comes closer to being universal without a couple of the really big limitations that previously existed—that of discriminating against people with preexisting conditions and then capping them out at some arbitrary figure—that’s huge,” he says.
There’s this broad theme out there of trying to get away from fee-for-service with various models, accountable care organizations, and other experiments, to see if they will lower cost and improve quality.
—Timothy Laing, MD
An Uneven Exchange
Not everything has gone according to plan, however. One of the law’s most visible elements, the health insurance exchange or marketplace, got off to a rocky start Oct. 1 when computer issues hobbled the main healthcare.gov portal for 36 state exchanges and plagued many state-run sites as well. Older and sicker patients are generally more motivated to keep trying to enroll, despite the balkiness of the main web-based portal. The same isn’t necessarily true for younger and healthier people, dubbed “young invincibles,” whose participation will be vital to help balance each state’s risk pool. Because they generally seek out care far less often than older consumers, their lower medical costs can help compensate for higher expenditures elsewhere.
If too few sign up, however, a state’s risk pool may be imbalanced toward costlier patients, causing insurance premiums to rise and creating a vicious cycle that destabilizes the market and makes more expensive insurance less attractive to younger people. It’s too early to say whether the exchanges can meet the Congressional Budget Office’s prediction of seven million enrollees by the end of the 2014 enrollment period (and 13 million by 2015).1 But analysts say the composition of the risk pool—something that should be clearer this spring—may provide a glimpse of the ACA’s long-term financial viability.
Instead of a consistent pattern across the country, the exchanges also will be shaped by local market forces, such as the number of competitors and the extent to which cheaper plans will try to limit access to more expensive providers. In exchange for lower premiums, some of these insurers are offering “skinny networks” that give consumers more limited options for providers. “A primary objective in the marketplace is to offer the cheapest plan possible, and to do that the insurers are going to look at who are the least expensive providers,” says Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges.
“I think the challenge is who’s going to absorb the extra patients, who will cherry-pick them, and who will take everybody?” says Salahuddin Kazi, MD, associate professor of medicine in the division of rheumatic diseases at the University of Texas Southwestern Medical Center in Dallas. Rheumatologists who are already flush with patients can afford to be selective and watch from the sidelines. Doctors starting a new practice, however, may be much less choosy. “Will that become an unsustainable business model for them?” he asks.
And with the rise of accountable care organizations and practice consolidation, Dr. Laing says some independent doctors could be frozen out of exchange-based insurance plans altogether. On the flip side, he says, “everyone says there’s going to be way more patients than there are doctors, that we’re not going to be able to keep up with demand. Ultimately, I don’t know that anybody is going to starve.”
Increased emphasis on teamwork and delegation of tasks that don’t require a physician’s level of training is something that’s going to get a lot more attention moving forward.
—Ann O’Malley, MD
A Question of Access
How the healthcare system will accommodate the influx of newly insured, in fact, remains one of the biggest unknowns. Mitchell says the existing doctor shortage—almost evenly split between primary and specialty care—is already worsening due to the sheer number of Baby Boomers entering Medicare. At the same time, she says, one in three doctors in the U.S. is now over the age of 60. Whether through Medicaid or the marketplace, the ACA’s coverage expansion will exacerbate the shortages. “It’s not to the level of the Boomers entering Medicare, but it certainly is having a major impact on access issues, and exacerbating the shortage, again, across specialties,” she says.
Other analysts say the extent of the capacity problem will depend in large part on location. “We already have a supply and demand imbalance,” says Dr. Kazi. At Parkland Memorial Hospital, where he sees some of his patients, “we get many more rheumatology consults and requests to see new patients than we can handle.” Dr. Kazi sees the Dallas-Fort Worth area as a microcosm of the sheer variability in capacity that exists across the United States. “We have rheumatologists that are very, very busy—and saturated,” he says. “And then we have rheumatologists who have availability this week.”
The access question is more complicated in the roughly two-dozen states, such as Texas, that have chosen not to expand Medicaid—an option granted by the U.S. Supreme Court in its June 2012 decision that upheld the law’s main tenets. According to a recent analysis by the Kaiser Family Foundation, roughly five million uninsured adults may now fall into a “coverage gap.”2 In essence, they will earn too much to be covered under the highly variable Medicaid caps established by individual states, but too little to receive any federal tax credits to help pay for insurance in the exchanges. With limited options, the report suggests, they are likely to remain uninsured.
Who’s going to absorb the extra patients, who will cherry-pick them, and who will take everybody?
—Salahuddin Kazi, MD
Meeting demand also means training more doctors, and Mitchell worries about a pipeline that is already underfunded. Federal support for physician training has been frozen since 1997, and further declines in the clinical income that subsidizes training would place additional pressure on the educational mission of teaching hospitals, Mitchell says.
Another one of the plan’s biggest goals and part of its name—affordability—also seems to vary considerably by geography. A recent analysis by the New York Times, for example, found that 58% of all counties served by the federal-run exchanges offer plans from only one or two insurance carriers. The relative lack of competition in many markets has created some huge cost disparities in premiums between neighboring states—and even neighboring counties.
Although the new mandates were designed to improve insurance standards, they sparked another firestorm when millions of Americans began receiving policy cancellation notices. Because many private insurance plans sold to individuals no longer met the ACA’s minimum requirements, insurers began dropping those plans or asking enrollees to switch to other ones. In November, President Barack Obama bowed to mounting political pressure and announced a reprieve that allows insurance companies to renew existing policies for another year, in an effort to stem the mass cancellations.
Taking the Long View
Although Dr. Kazi says he sees the ACA as “one step toward greater equity and transparency and a value-based healthcare system,” he stresses that additional reforms will be needed. To truly meet the law’s aims, he says, the healthcare system likely will need to move toward more uniform prices to eliminate the incentive to see some patients but not others, and to provide more incentives to maintain continuity of care. Third, it may need to group treatments for conditions like rheumatoid arthritis as a single episode of care, in order to align incentives to work together as a coordinated team of providers.
A successful system of exchanges, however, could have several long-term consequences. “If, in fact, the exchanges offer good insurance products that the public begins to accept and find that they have good information to make choices, it could affect the prevalence of employer-based insurance,” says Robert Berenson, MD, an institute fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy. Over many years, employers could begin moving their employees into exchanges rather than providing direct healthcare benefits.
“If the exchanges work as advertised and they end up having a very competitive landscape,” Dr. Laing says, “maybe people will be a little more tuned in to what their coverage is because they’ll actually have to shop for it rather than having a limited number of choices.” This comparison shopping, in other words, could increase consumers’ awareness of costs and benefits and aid discussions with rheumatologists.
A viable exchange system also may help accelerate the trend toward more consolidation of physician practices or alignment with larger entities. Despite concerns over skinnier networks, for example, the more tightly controlled access to providers under certain plans dovetails with the ACA’s heightened emphasis on more integrated accountable care organizations (ACOs).
ACOs and other lower-profile provisions that enjoy more bipartisan support, in fact, could ultimately play key roles in reshaping healthcare delivery. Many of these reform efforts have been launched as pilots or demonstration projects. Salt Lake City–based healthcare consulting firm Leavitt Partners tallied nearly 500 ACOs through the end of July 2013—more than double the total in June 2012.
Other ACA provisions are levying fines based on excessive hospital acquired conditions or readmissions, and adjusting reimbursements based on e-prescribing, the Physician Quality Reporting System (PQRS), meaningful use of electronic health records, and other mandates. “There’s this broad theme out there of trying to get away from fee-for-service with various models, accountable care organizations, and other experiments, to see if they will lower cost and improve quality,” Dr. Laing says.
Hovering over all the change is the specter of more paperwork and bureaucracy, but Dr. O’Malley sees plenty of potential for increased efficiency. “I think increased emphasis on teamwork and delegation of tasks that don’t require a physician’s level of training is something that’s going to get a lot more attention moving forward,” she says. “It’s something that can help us function more effectively and efficiently so that we can make the providers that we do have go further and meet the population’s healthcare needs.”
Bryn Nelson is a freelance medical writer based in Seattle.
References
- Congressional Budget Office. CBO’s May 2013 estimate of the budgetary effects of the insurance coverage provisions contained in the Affordable Care Act. Available at http://cbo.gov/sites/default/files/cbofiles/attachments/44190_EffectsAffordableCareActHealthInsuranceCoverage_2.pdf. Accessed November 22, 2013.
- Kaiser Family Foundation. The coverage gap: Uninsured poor adults in states that do not expand Medicaid. Published October 23, 2013. Available at http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid. Accessed November 22, 2013.
- Congressional Budget Office. Cost estimate for pending health care legislation. Published March 21, 2012. Available at http://cbo.gov/publication/25049. Accessed November 22, 2013.
