Conference Coverage
CHICAGO – The Affordable Care Act may still be stumbling into place, but it’s here to stay, bringing with it changes especially acute for private physicians.
That’s the consensus of a panel of experts who presented their perspective on the impact of "Obamacare" at this year’s annual meeting of the American College of Chest Physicians.
"Younger physicians are more supportive of the ACA than older physicians," said to Dr. Akram Khan of Oregon Health & Science University, Portland, referencing a survey that found 80% of physicians between 25 and 39 years were optimistic about the future of health care in America. "Older physicians have adapted to the fee-for-service system we currently are in, and so are more ambivalent about the effects of the ACA than [the younger generation] than younger physicians who have not adapted to the system yet."
Private practitioners pay more
Regardless of the number of years in practice, Dr. Edward J. Diamond told the audience that even though he had tried to "dig my head in the sand and tried not to think about this, but unfortunately we are compelled to address it."
The president of large, multisite pulmonary practice in suburban Chicago, Dr. Diamond listed some of the pressing concerns he said should be on the minds of all private physicians, who are almost always employers as well.
The first concern he noted was abiding by the ACA mandate that employee premiums do not exceed 9.5% of the employee’s gross income, and that employer-sponsored plans share at least 60% of the total cost.
Because the cost of private insurance is tied to that of public exchange enrollment and are therefore fluid, Dr. Diamond said this equates with "an enormous administrative burden. We as employers are now going to have to monitor the marketplace of health plans because we’re going to have to compare what we’re offering our employees to what they can get in an insurance exchange."
Further complicating coverage, he said, would be the need to tier coverage to accommodate the variances in office and medical staff salaries vis-à-vis the ACA’s definition of affordability.
Drag on system "real"
Dr. Mark Levine, chief medical officer for the Denver office of the Centers for Medicare and Medicaid Services, said that despite the multitudinous problems with the official ACA website, healthcare.gov, "It really does make comparisons of health plans much easier." He added that only "qualified health plans are listed, which means that they are of known benefit structure and quality."
Regarding the ACA’s direct effect on patient care, Dr. Diamond said that while practices that can accommodate a larger patient load will benefit, quality likely will suffer in practices that are already operating at capacity.
"You’ll be seeing patients that are more complex because they were uninsured in the past and have multiple medical problems," he said, adding that this will take more time and will be reimbursed at lower rates than was done previously.
Dr. Levine concurred, "There will be a drag on the system at first" because of the surge in patients with complex medical needs left untreated by their previously uninsured status.
"Perhaps everybody else needs to chip in to account for that and for the kind of cost shifting we have seen and these phantom pricing mechanisms that have been so common in American health care," said Dr. Levine. "The lack of coverage to a needy population is only going to exacerbate the systemic concerns."
Regardless of burdens shouldered, plenty of Americans will remain needy, according to Dr. Jonathan Pak, also of the Oregon Health & Science University.
"The goal is to get everyone insured, but we will be nowhere close to that 10 years into the future," he said, citing data released by the Congressional Budget Office earlier this year, indicating that in the year 2022, 31 million will remain uninsured. "Make no mistake, this is not a universal health care plan."
Impact on critical care
The ACA might actually benefit the bottom lines of hospitalists and intensivists, said Dr. Diamond. "In the critical care arena, you’re going to have an improved payer mix, you’re going to have the same number of patients, and you have a business model [in which] you don’t have clerical staff," he said.
Dr. Pak had a different view. Already shrinking numbers of critical care resources such as beds and critical care staff likely will be further stressed under the ACA, forcing up per-bed costs and exacerbating shortages of intensivists. "I think, despite many improvements, it won’t be very long before we have to face structural health reform all over again."