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Experts say the impact on policy will likely be greater than on individual physicians and practices
Donald Trump's presidency will almost certainly lead to major changes for healthcare-but not necessarily for individual doctors, and probably not right away.
Trump’s best-known pledge regarding healthcare is to speedily repeal and replace the Affordable Care Act (ACA). But completely undoing the law could take years and will encounter fierce resistance both in and outside of Congress. For example, in early December a coalition of hospital groups warned that ACA repeal could “decimate hospitals’ ability to provide services, weaken local economies and result in massive job losses.”
Further reading: GOP Obamacare replacement bill puts physicians, patients in charge
And even repeal of the law probably won’t significantly change most aspects of healthcare delivery, says Russell Libby, MD, a board member of the doctors’ advocacy group The Physicians Foundation and a pediatrician practicing in Virginia.
“I think repeal and replace is a political statement, not necessarily a practical one,” says Libby. “The care that is being provided to a lot of people in this country depends on evolutions that have happened since the ACA was implemented, and it’s going to be delicate to dismantle.”
Libby cites the law’s promotion of new practice and payment models and the growing emphasis on team-based care as trends that are unlikely to change. “We’ve moved into a phase that I think is really irreversible and looks much more at what’s important to patients and how best to serve them,” he says. “And ultimately that’s what best serves healthcare and our profession.”
In addition to the ACA pledge, the Trump campaign’s website offers a few other clues about the new administration’s goals in the healthcare arena. Among these are:
Trump has also announced his choices for two positions that are key for developing and implementing healthcare policy. His nominee for secretary of the U.S. Department of Health and Human Services is Tom Price, MD, a U.S. representative from Georgia, former orthopedic surgeon, outspoken critic of the ACA and supporter of Medicare privatization.
For administrator of the Centers for Medicare & Medicaid Services, Trump plans to nominate Seema Verma, MPH, president and CEO of SVC Inc., a health policy consulting firm headquartered in Indianapolis. Verma helped design plans for states that initially declined to expand Medicaid coverage following passage of the ACA.
These plans generally include some form of financial contribution or work requirements for Medicaid beneficiaries. One such plan was implemented by Indiana governor, and now vice president-elect, Mike Pence.
With the caveat that nothing is yet certain, here’s a look at how some issues of importance to primary care doctors might unfold during the Trump administration.
As noted above, Trump has frequently promised to repeal the law and replace it with a system providing Americans with “great healthcare at a fraction of the cost.” But how and when repeal occurs remained open questions before the new administration took office.
In early December, for example, several influential Republican senators said they would make a vote on ACA repeal their first order of business after Trump’s inauguration, but delay the actual repeal for as long as three years. During that time, they and the Trump administration would work to develop a replacement for the ACA.
But even if the ACA were to disappear, the impact on the regulatory and financial challenges of greatest concern to primary care doctors probably will be limited at best.
“When you look at the ACA, it’s really more about insurance, much less about physician practice and healthcare delivery,” Libby says. “It’s more about access than about process.”
Of course, the elimination of a law as sweeping in scope as the ACA would almost certainly have some impact on individual physicians and practices, but it varies depending on the practice’s situation. For Fred Nichols, DO, an OB/GYN in northern New Jersey, the financial impact of repeal would be minimal. The vast majority of his patients get health insurance through their employers, Medicare or the military.
“So we’re talking about maybe a 10% portion that’s affecting me. If the ACA went away tomorrow, it would mean a little hit, but it wouldn’t hurt me a lot by any means,” he says.
For Nichols’ staff, however, the impact could be significant. That’s because many of the new patients who came as a result of the ACA had previously gone long periods without seeing a physician, and thus needed follow-up care from specialists. Often they turn to his staffers for help in locating and making appointments with specialists, creating a time burden for them, he says.
In addition, his office staff began spending more time on tasks like obtaining prior authorizations as more people obtained healthcare coverage.
“All of a sudden all these new people came on the market, but there were still the same number of phone lines going to the next level for approval of tests and everything else,” he recalls. “The infrastructure wasn’t there to support it.”
On balance, Nichols thinks ending the ACA will be a plus for physicians. “With Mr. Trump in place now, looking at [the law] from a purely business standpoint, I think his acumen really will help. The system isn’t working, so things can only get better.”
Other physicians point out that the law is having beneficial effects that go beyond the financial. “The ACA has begun to move the ball forward in accountability among different care settings,” says Antonio Gamboa, MD. Gamboa, a former hospitalist, is chief executive officer of Austin, Texas-based Elite Patient Care, which provides services to patients making the transition from hospitals and other acute care settings back to the community.
Gamboa says he was skeptical about the ACA at first, but now has come to support it. “I saw how it began to create accountability through the implementation of rehosptialization penalties and other regulatory actions,” he says. Before the ACA took effect, many hospitalists-including him-took the attitude that their responsibility for a patient ended when the patient was discharged.
“Now, the ACA has created a sense that attitude is no longer sustainable,” he adds. “We’re all having to become better resource utilizers in protecting the Medicare dollar.”
According to his campaign’s website, Trump favors “modernizing Medicare” to prepare the program for the challenges of an aging population. Most healthcare policy analysts interpret that as endorsing the concept of a “premium support” system for Medicare-an approach long advocated by Paul Ryan (R-Wisconsin), Speaker of the U.S. House of Representatives, as a way of controlling Medicare spending. Price has endorsed the concept as well.
Under such a system, the federal government would pay a fixed amount for each Medicare beneficiary, explains Stuart Guterman, a senior scholar in residence at AcademyHealth, a Washington, D.C., healthcare think tank. The beneficiary would use that payment either to enroll in a private plan-similar to a Medicare Advantage plan-or in traditional Medicare.
Competition among the plans would be expected to hold down premiums. But if a plan cost more than what the government provides, the difference would come out of the beneficiary’s pocket.
For the government, the advantage of such an approach would be to make spending on Medicare much more predictable. “Premium support allows the government to basically say, ‘here’s how much we’re going to spend on each beneficiary, and that’s it.’ They don’t have to worry about whether the person needs more care than the support pays for. That’s on the beneficiary now,” Guterman explains.
The drawback would be temptation to skimp on quality in order to hold down premiums. “We all know that low cost can come about because a plan is efficient, or because they don’t care [about quality] and lowball,” he says. “And we know that consumers are likely to be attracted to low-cost plans, even if they’re low quality, if they’re faced with the prospect of having to pay out of their own pocket for higher quality.”
Medicare premium support likely would mean even more pressure on physicians and medical practices to hold down costs, as insurers try to keep premiums low by further narrowing provider networks, Guterman predicts. “Both individual docs and group practices would be under more pressure from payers to accept lower rates or be excluded from networks, because consumers are attracted to plans with low premiums, because they’d have to pay the difference themselves,” he says.
Similar to Medicare premium support, proposals to allow insurance companies to sell policies in multiple states have gained support in Congress, primarily among Republican lawmakers. Proponents say it could make insurance more accessible by increasing competition and thereby hold down premiums. In so doing, they say, it could also help consumers who now purchase insurance on the ACA’s insurance exchanges
While the idea makes sense intuitively, it would need to overcome numerous legal and political obstacles to become a reality, says Dania Palanker, MD, MPP, assistant research professor at the Center on Health Insurance Reforms at Georgetown University. Chief among these is that insurance is overseen by states, and states vary widely in their requirements for insurers and protections for consumers.
“The reason an insurer would come in with a cheaper plan would be because that company is offering a plan from another state that might not meet the adequacy requirements [of the state where the policy is being sold],” Palanker explains. “So basically it’s a backdoor way of getting around all the protections that many states have been building up for decades.”
Palanker adds that insurance companies generally have established relationships with providers and brokers in states where they have long done business, which a new payer would lack. “For a new entity to come into a state, they’d have to create a network from the ground up, which is not an easy process,” she says. “The start-up costs associated with that process would be quite high.”
Moreover, she says, if many companies started selling policies out of one particular state, that state’s insurance office might not be prepared to handle the increased volume of consumer questions and complaints they would receive.
Even if a robust market were to develop for sales of insurance across state lines, Palanker doubts it would be enough to cover all the people who would no longer have insurance after the ACA is repealed. “This on its own doesn’t get anywhere near the expansion [of coverage] provided by the ACA,” she says.
Although the possibility of ACA repeal has garnered the most attention from the public and the press, it is Medicare payment reform-as embodied in the Medicare Access and CHIP Reauthorization Act of 2015-that will most affect the day-to-day operations of most medical practices. CMS released the final rule for implementing the law in October, prior to the election.
MACRA’s fate remained unclear in the interim following the election and before the new president took office. “We don’t foresee wholesale changes [to the law] because it was passed with strong bipartisan support,” says Walter Gorski, director of regulatory affairs for the American College of Physicians.
On the other hand, before the election Price was among the signatories of a letter to CMS expressing concern about the law’s reporting requirements and overall complexity. But that letter was sent before release of the final rule, and Price has not said whether the rule addressed his concerns.
Gorski says that one possible MACRA-related change under the new administration would be the Center for Medicare and Medicaid Innovation, which is charged with developing new payment models for Medicare. In some cases it has the authority to implement those models without Congressional approval, which has drawn concern from some in Congress.
Although established under the Affordable Care Act and thus not technically a part of MACRA, Gorski says the center is nevertheless “critical to MACRA’s functioning.
CMMI is a tool to test new types of payment models,” Gorski explains. “So as we move from a system that rewards volume to one that focuses on value and outcomes, CMMI plays a vital role in that it allows CMS to test new ideas.”
Gorski is optimistic that CMMI will continue under the Trump administration. “I think the new administration and Congress will make some changes to it, but will leave the tool there, because they may want to test some new payment ideas,” he says.
Doctors often complain that the high price of prescription drugs, whether branded or generic, prevents their patients from adhering to treatment plans. Trump, on his campaign’s website, says he will address the problem by eliminating market barriers for providers offering “safe, reliable and cheaper products” and allowing consumers access to “safe and dependable drugs from overseas.”
Speeding the process of generic drug approvals could well hold down their escalating costs, says Erin Taylor, Ph.D., a policy researcher with the RAND Corporation. She cites the example of the steep price increase in the epinephrine auto-injector (EpiPen).
“That’s been around for a long time, and even though it’s generic, they (Mylan) are the only manufacturers,” she says. “So the idea of creating incentives to enter the market might help temper these wild price increases among the generic drugs.” It would have the additional advantage of being consistent with Republican free-market philosophy, she notes.
Further reading: How doctors can overcome payment obstacles in 2017
As for allowing drug importation, Taylor maintains it probably wouldn’t produce the savings many lawmakers and consumers expect. That’s because most comparisons of drug prices between the U.S. and other countries reflect the list price of the drugs, she says, and not the price that most consumers pay after discounts negotiated by insurance companies and pharmacy benefit managers.
Also uncertain is how the mechanics of an importation program would work, she says. For example, would U.S. insurance companies negotiate discounts with pharmacies in the exporting countries, or would consumers have to pay the full cost of the drug out of pocket and submit a claim for reimbursement? “The whole complexity of administration raises questions about whether it would actually reduce prices in the end,” she says.
Ensuring the safety and quality of imported drugs would also be an issue, she points out. It would probably require the Food and Drug Administration to increase its inspection capabilities. “That leads you to think about the issue of cost,” she says. “It might not feed into the direct price of the drug, but it does raise questions about whether it lowers the overall cost to the healthcare system.”
Although overhauling the nation’s medical malpractice laws is not a topic Trump has addressed, it is one that physicians have long desired, and Republicans have advocated. And with the GOP in control of the presidency and both houses of Congress, some observers think now would be an opportune time to do it.
In 2016, a malpractice reform bill known as the Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act was introduced in Congress. The legislation, which didn’t make it out of committee, was modeled on laws in Texas and California that limit the amounts juries can award plaintiffs for pain and suffering, explains Elizabeth Healy, assistant vice president for government relations at The Doctors Company, a national medical malpractice insurance company.
Passage of such legislation would likely benefit physicians, Healy says. “You would definitely see the impact at the practice level, because [premium] costs and frequency [of lawsuits] are lower in California and Texas than in states without similar reforms. So it would definitely have an impact on physicians’ rates and how often they are sued.”
Hot topic: Physicians should just say 'no' to MACRA
Healy warns, however, that malpractice reform is far from guaranteed even with a Republican president and Congress. Some senators and representatives think the issue should be left up to the states, and a reform bill could well face a filibuster in the Senate. Moreover, Trump himself has not said where he stands on the issue. “So I think it will be proposed, but it’s not a shoe-in just because we have a Republican trifecta,” she says.
During his campaign, Trump frequently promised to reduce income taxes, and a House and Senate dominated by Republicans will almost certainly agree to whatever he proposes. But primary care doctors likely won’t see much difference in their after-tax incomes, says Mike Arnow, CPA, CFP, senior director of financial planning for Sattell, Johnson, Appel Financial Advisory in Milwaukee, Wisconsin.
Trump has proposed consolidating the current seven income tax brackets income into three, thereby eliminating the top two brackets of 39.6% and 35%. Arnow points out that those brackets apply on adjusted gross incomes (AGI) starting at $470,000 and $416,000, respectively, for married couples filing jointly-amounts likely to exclude most primary care providers.
However the ACA did include a 3.8% bump in the Medicare tax on AGIs starting at $250,000 for married couples filing jointly. “There we could start picking up some PCPs, especially in a two-income family,” Arnow says. The legislation also included a 0.9% Medicare payroll tax increase on compensation of $250,000 for married joint filers and $200,000 for single filer that took effect at the start of 2013. Repealing that tax also would benefit many PCPs, Arnow points out.
Arnow adds that nothing in the Trump administration’s tax proposals has caused him to change what he calls his “three brown bag” advice to clients: one bag is for discarding unopened stock investment statements, the second is for packing lunches as a way to spend less and save more, and the third is for “breathing into when you watch cable TV news until your lightheadedness goes away.”