Several key provisions of the controversial law are set to go in effect over the course of 2013. See how they'll shape the practice of medicine.
As provisions of the Affordable Care Act (ACA) are implemented, primary care physicians (PCPs) need to reshape their practices and be prepared to juggle the sometimes-contradictory goals of increasing quality while managing more patients.
“There is a lot of good news here, with a lot of people getting insurance coverage, but there is a real challenge in the transition,” says David Bronson, MD, FACP, president of the American College of Physicians.
“The lesson we learned from Massachusetts is that having more patients have insurance will put a strain on all practices, not just primary care,” he adds. “Physicians need to be looking for smart ways to expand their practices, either through adding partners or associates or increasing their use of midlevel providers. They need to find ways to provide care to more patients and move toward using new models of care, such as Patient-Centered Medical Homes [PCMHs].”
Reid B. Blackwelder, MD, FAAFP, president-elect of the American Academy of Family Physicians, adds that ACA will help narrow the long-standing gap in pay between primary care and specialty care providers.
“The ACA recognizes primary care as foundational to any change,” Blackwelder says. “It finally puts primary care in its proper place. It may not necessarily bring in lots more money right away, but it is a huge change in philosophy.”
Several aspects of the ACA are definitely bringing more revenue to some primary care practices. For example, Blackwelder mentions the Incentive Payments for Primary Care Services program. It allows primary care providers to be paid quarterly an amount equal to 10% of the payment amount for services paid under the Physician Fee Schedule. The program is in effect through 2015.
“This is a very good thing, helping [PCPs] get more money for care they were already providing,” he says, “but we need to figure out how to make it permanent.”
Another plus for primary care is that as more patients move into Medicaid starting in January, states will be required to pay no less than 100% of Medicare payment rates in 2013 and 2014 for primary care services.
Bronson calls this parity a strong win for the profession. Blackwelder agrees, saying it will increase the number of doctors who are willing to see Medicaid patients, but he expressed concern about what will happen when federal funding for this effort runs out in 2 years. States will have to option to continue it-or not.
“Family practitioners value long-term relationships, not short-term ones. What will happen to these patients if this coverage runs out?” Blackwelder asks. “Two years is a good start, but it is not enough.
“It may be hard to keep our doors open if this changes and we are left with a lot of patients who cannot pay us,” he adds.
Bronson, however, says he is optimistic about what will happen at the end of the 2 years.
“I don’t think we will go back to the same system,” he predicts. “They will figure something out by then.”
INCREASED PAYER COLLOBORATION
Another promising element of the ACA is the Comprehensive Primary Care Initiative, which aims to foster collaboration between public and private healthcare payers to strengthen primary care. In it, Medicare will work with commercial and state health insurance plans and offer bonus payments to PCPs who better coordinate care for their patients.
Primary care practices that participate will be given resources to better coordinate care for Medicare patients (an average of about $20 per patient), to cover the costs of things that improve care, such as telephone and email management of conditions and oversight of hospital discharges.
Blackwelder expects that this pilot program will help further demonstrate the value of the PCMH model. Currently, the pilot involves some 500 primary care practices in Arkansas, Colorado, Kentucky, New Jersey, New York, Ohio, Oklahoma, and Oregon.
“This type of payment reform has to happen. Fee-for-service doesn’t allow for prevention and counseling patients on healthier lifestyles,” he says. “We will always have some type of fee-for-service, such as when a procedure is done, but a blended approach is better for everyone.”
TAKING NEW PATIENTS
With uncertainties about incentives such as these lurking, though, some physicians might be reluctant to take on new patients, and Bronson emphasizes that this decision is their right to make. He predicts, however, that most PCPs will find it difficult to resist pressure from existing patients and phone inquiries and will find ways to run their practices the best they can while expanding their patient bases.
Blackwelder advises doctors who are torn about accepting additional patients to look for ways to work within the system to use all resources to maximize patient care. For example, he says, there is nothing wrong with patients receiving their flu vaccines at pharmacies as long as care is coordinated, not duplicated.
“We need to work in teams better,” he says. “We shouldn’t fight over who sees who. We need to get patients to the right person at the right time and work with midlevel providers to give better care to our communities and save money.”
Blackwelder anticipates financial rewards for those who are creative. “We need to work smarter, not harder,” he adds.
As the nation increases its demand for care, shortages of PCPs and nurse practitioners (NPs) will become ever more evident. Bronson is optimistic that market forces will respond, rewarding primary care providers and providing incentives to medical students who choose primary care.
“Primary care has been starved economically for 30 years,” he says. “In the long run, primary care will need more money to meet the needs of accountable care organizations and various patient populations.”
To be sure, the federal government has formed the Prevention and Public Health Fund to increase the supply of primary care providers by channeling resources to create more primary care residency slots, support physician assistant and NP training, and establish NP-led clinics in medically underserved communities.
Blackwelder points out that another shortage is looming that is not talked about much: registered nurses. Although shortages in the United States have improved in recent years, they are projected to increase again in the future.
He cited an article that appeared in the July/August 2009 Health Affairs, in which Peter Buerhaus, PhD, RN, and coauthors found that although the current nursing shortage has eased, at least in part due to the recession, the need for registered nurses is projected to grow to 260,000 by 2025. A shortage of this magnitude would be twice as large as any nursing shortage experienced in the United States since the mid-1960s, the article concluded, pointing to a rapidly aging workforce as a main contributor to the projected shortage.
“This is not talked about a lot, but it is a critical aspect,” Blackwelder says. “We need every member of the primary care team to be in place as we talk about making primary care the foundation of our healthcare system.”
EFFECT ON GROUP PRACTICES
Another aspect of the ACA is that it requires that a value-based payment modifier (VBPM) be applied to all physicians by January 1, 2017, based on their ability to balance high-quality care with cost-effectiveness. Medicare plans to adjust physician payments using quality data from the Physician Quality Reporting System (PQRS) and cost data from Medicare claims for fee-for-service patients.
The modifier will first be applied to groups of 100 or more eligible professionals in 2015, according to Miranda Franco, government affairs representative with the Medical Group Management Association (MGMA). It originally was going to be applied right away to groups of 25 or more, but the MGMA and other organizations lobbied for the move to 100.
“We felt the modifier was untested and still have concerns regarding methodological and technical issues,” Franco says. “However, increasing the threshold to 100 will narrow the population immediately impacted and will hopefully alleviate some of these concerns.”
Practices of more than 100 providers that do not participate will be subject to a 1% penalty in 2015, based on 2013 data.
Smaller groups will not be affected in the first reporting year, but Franco says that because the Centers for Medicare and Medicaid Services is still committed to applying the modifier to all physicians by 2017, solo practitioners and small groups should consider participating in the PQRS.
“It might ease the burden of the transition to start now before PQRS moves into a penalty phase,” she says.
Under the modifier, practices that elect to meet quality and cost standards may receive higher payments. Because the VBPM is required to be budget-neutral, however, the higher payments will be funded by paying less to practices that report lower quality and higher costs.
Data collection to determine whether the modifier would be applied positively or negatively would take place 2 years earlier, which is another reason Franco suggests smaller practices consider starting to report their data as a group now.
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