The Affordable Care Act

By Helen K. Kelley

From ATLANTA Medicine, 2014, Vol. 85, No. 3 

The Affordable Care Act (ACA), the national health reform law passed in 2010, was enacted with the purpose of providing new funding for public health and prevention, bolstering the healthcare and public health workforce and infrastructure, and fostering innovation and quality in healthcare. Reasons for the law included a high-uninsured rate, unsustainable healthcare spending, lack of emphasis on prevention of disease, poor health outcomes and health disparities across demographic lines.

In January this year, some provisions of the ACA went into effect that will bring about major changes for physicians. In an article published on Dec. 13, 2013, U.S. News and World Report stated that doctors should prepare themselves for three major changes in how they as a profession do business: a shift from private practice to medical networks, a full integration of electronic health records and changes in the healthcare payment model.

Atlanta Medicine recently spoke to two local physicians – Dr. Lisa Perry-Gilkes, chair of the Board of Directors of the Medical Association of Atlanta and in practice with Polaris Medical Group, and Dr. Thomas E. Bat, CEO of North Atlanta Primary Care – who shared their opinions and thoughts about these changes and how the Affordable Care Act has affected the way they do business.

How has ACA affected patients’ care?

Dr. Perry-Gilkes: As of now, it hasn’t had any effect on my practice at all. The changes that go with the ACA don’t impinge on what I do currently and haven’t affected my ability to care for patients. However, I don’t know what it will be like next year.

Dr. Bat: The ACA has caused many patients to experience increased stress due to concerns about costs of premiums, access to care and ability to continue seeing their doctors, as well as general confusion about whether or not the medications they are taking are covered. These patients need to sit down with a caring physician to discuss all these issues and to “re-establish” care, even though this is time-consuming for both physician and patient. Many patients with chronic debilitating diseases are struggling with this the most.

Simply finding out which physicians and health systems accept the new exchange patients is a challenge. Some patients who previously had commercial insurance and have been “switched” to exchange plans are now finding they have to choose a primary care physician and make a visit just to get a referral to continue specialty care. This gatekeeper model has not always worked well in the past, but encouraging patients to have their own personal physician is a good thing.

Has the State of Georgia’s political position toward ACA made a positive or negative impact?

Dr. Perry-Gilkes: Honestly, I believe we missed out on an opportunity to have more people covered. About 60 percent of Georgia residents would have liked the Governor to go with the Affordable Care Act, but he didn’t.

The lack of providers is a real issue – in Georgia, we still have sick people who are not covered. You have to take into consideration the disparity between metro Atlanta and the rest of Georgia – there’s a big difference in the accessibility of care for people who live in or near a big city and people who live in rural areas. What the federation of medicine needs to do is try and find the happy medium between metropolitan and suburban and rural healthcare. There isn’t one shoe to fit all the problems, so it’s going to take some compromise.

It’s important that we, as physicians, let our patients and legislators know what we can do to make things better.

Dr. Bat:Our state leaders have looked at participation in the exchanges, accepting the Federal Exchange instead of building a state-based exchange. Considering all of the unclear issues and problems in the exchanges, this appears to have been a good decision. The exchanges have not functioned well, as the technology and the goals are not well defined by ACA.

The political decision to not expand Medicaid is a two-edged sword. Leaving federal money on the table that is especially needed in our rural health systems can be devastating. However, growing a payment system that does not work makes no sense. Our practice elected to start taking Medicaid again, as the government promised Medicare payment rates or parity two years ago. But the state has failed to process claims for Medicaid at the promised rates.

Medicaid patients are always a challenge due to their income, but many times they have accompanying educational and personal issues that create additional challenges. To not compensate providers for these challenges is a failed policy. Building and enlarging a failed policy will lead to a system that does not work for a greater percentage of our population. There are better ways to deal with the uninsured and poor; certainly block grants and healthcare vouchers are worth exploring.

What suggestions would you make to improve ACA?

Dr. Perry-Gilkes: I think we can find ways to improve access to healthcare. We’re going to have to come to a meeting of the minds to get all citizens of Georgia covered.

It’s not an insurmountable problem, but it’s going to take physician leaders and legislators working together to solve it. Healthcare is a “cornucopia” of challenges. If everyone would give a little, we can make a change.

Dr. Bat: I don’t think any one person can comprehend the challenges in this broad piece of legislation. A one-size-fits-all federal mentality does not work in a country as large and diverse as ours.

One of the impending parts of the ACA, referred to as the Independent Payment Advisory Board (IPAB), will be a disaster if implemented. The amount of analytics required to comply with the government’s guidelines for a Physician Quality Reporting System (PQRS) and Meaningful Use (MU) are making it virtually impossible to focus on patient care while documenting what the government requires.

Mandatory enrollment for individuals and employers has caused a great deal of grief in the political world, yet we all need insurance. Encouraging our population to participate is a much better route than mandating coverage.

How has ACA affected your business?

Dr. Perry-Gilkes: Currently, it hasn’t affected my practice except for making changes to implement the electronic health record for patients. That’s had a significant impact.

And I wish the Medicaid plans we have in Georgia now were not so difficult to work with.

Dr. Bat: I think it’s too early to tell. As we move to “at-risk” population payment models, the more we do for our chronically ill patients, the worse our physician profiles will appear in government rankings. Of course, this will affect our pay and “bonuses.” We are exploring population-focused care models that are based on both capitation and fee-for-service, with bonus pools that include insurance companies, health systems and private IPAs.

Since we are currently a PCMH [patient-centered medical home] model, we believe population health is important, but the team serves one patient at a time to maximize outcomes. The newer compensation models will challenge us, because they see the “population” outcomes as more important than the “individual” outcomes. And, of course, all of this will be based on quality criteria that is truly reflective of economic data.

What do your physician colleagues think of ACA?

Dr. Perry-Gilkes:The majority of physicians I know are so busy taking care of patients that the ACA is still in the back of their minds. Nothing has really hit us yet – we’re still taking care of patients just as we have been for the past several years.

Other than the implementation of electronic medical records for patients, I haven’t seen anyone making major changes. No one’s losing any patients, and no one’s turning any patients down, either.

I don’t think the sky is falling, but it may be dipping a little bit. Doctors will always be here, and they will always care for patients. It just may not be done exactly the same way as in the past.

As healthcare providers, we have a lot of work to do – and one of our tasks is to help align the patient’s expectations and responsibilities when it comes to care.

Dr. Bat: Most of my physician friends are overwhelmed, just taking care of their patients. A busy physician is pulled in too many directions to become very involved in the political system. Physicians are hurt by constantly being referred to as the problem that needs to be fixed. America has the greatest healthcare in the world, and the use of statistics to suggest otherwise is disingenuous.

Unfortunately, this has allowed the government and large health systems to take over and profit from the confusion. Look at the recently released Medicare payment data: physicians received 7 percent of the nearly $1 trillion Medicare budget. That 7 percent includes all the medications, chemotherapy, vaccinations and tests that they perform in their offices. Diagnostic centers, labs and hospitals collect the remaining 93 percent of healthcare dollars. Yet physicians are portrayed as the bad guys.

It’s hard to be a doctor today, but fortunately for Americans we love what we do, and we will continue to work for the betterment of our patients.