Do you remember when you were in college, shopping for courses to take next semester? If you were like me, you avoided classes where the instructors were graduate students or TA’s, opting for those taught by a professor. You didn’t want anyone less than an expert in charge of your education.
Patients seeking medical services at a primary care facility are increasingly encountering a similar issue: Even though they would prefer to receive care from a doctor, they might be handed over to a physician’s assistant or nurse instead.
Why is this happening?
It turns out that this is just one of several effects now being observed in the wake of the final establishment of the Affordable Care Act. The ACA’s requirements, especially with their focus on efficiency, cost-management, and standardization, have considerably shaken up medical practice management, often with adverse effects on primary care practices.
Here are four ways the ACA has failed primary care practices so far:
1. Cuts in Medicaid Funding
One of the ACA’s initiatives for 2014 has been to expand access to Medicaid. On the surface, this looks like a positive thing for primary care practices–the more patients, the better, right?
Unfortunately, that’s not quite true, since the increased access coincides with decreases in Medicaid and Medicare reimbursements for physicians as the government tries to rescue Medicaid and Medicare from bankruptcy and rally more funds to pay for new insurance consumers.
Aside from the cuts in reimbursements, the expansion of Medicaid coverage also undercuts funding for physicians because Medicaid and Medicare payments are significantly lower than those of private insurers.
Unfortunately, such regulations have not adequately taken into account future Medicare funding; and this makes it difficult for physicians to maintain a healthy financial situation, especially during a period where primary care practices are putting out considerable expenses to comply with the other ACA requirements and regulations.
2. New Reimbursement Standards
With the ACA has come a new focus on minimizing the number of services and procedures administered by healthcare facilities in order to save money. At the same time, the ACA demands higher quality care from physicians. In keeping with this, the federal reforms are calling for new methods of reimbursement which will be fee-for-outcomes as opposed to fee-for service.
Under this system, a primary care practice would receive a flat fee for a certain procedure or would be reimbursed based on the success (or lack thereof) of the service. Such “success” will be gauged by the health of the practice’s patient population, a criterion that is worryingly subjective.
To further this goal, the ACA has also instituted the Patient-Centered Outcomes Research Institute to investigate clinical practices in general and to establish new regulations accordingly. Doctors worry that the Institute will deprive practices of due payment, hinder clinical innovation, and interfere with doctor-patient decision making.
Also, the new reimbursement methods would include penalizations for hospitals that are viewed as having excessive readmissions. All of this means less remuneration and, in some cases, even more expenditure by physician’s practices.
3. Doctor Shortages
Despite hopes that the ACA would encourage people not to visit emergency facilities when primary care is available, newly insured patients have been flocking to ERs everywhere.
This is due in part to the doctor shortage, something that is not a direct result of the ACA but is nevertheless tied up in the new regulations: The ACA calls for higher quality service but fails to take into account the current physician shortage. In fact, the ACA may worsen it by putting into place regulations that could limit innovation, complicate medical practice, and create a generally negative atmosphere that disincentivizes people from entering healthcare professions.
As a result, patients at primary care facilities will increasingly be treated by nurses or physician’s assistants instead of seeing a doctor, something that could have a negative effect on the quality of patient care and satisfaction.
4. Increased Expenditure
Among the ACA’s requirements and regulations are several that have adverse financial consequences for doctor’s offices.
Practice management has particularly suffered with the institution of the ACA insurance exchange system, especially with the 90-day grace period for newly insured patients. As a result of the grace period, primary care practices have to verify new patients’ insurance as well as payment of that patient’s premium; and, if the patient has not paid his or her premium for whatever reason, insurance companies have the prerogative to either refuse to pay the practice for a patient’s treatment or even take back a payment the insurer has already made.
The necessity of calling insurers to see if a new patient has paid his or her premium adds to the workload of the practice manager and oftentimes of the other staff members, which is frustrating for the practice in general and significantly more expensive.
This expense comes on top of the Meaningful Use requirements concurrent with the ACA, which mean that practices must also make serious progress in the installation of electronic medical records. Either way, they pay a price—EMRs can be very pricey for primary care practices, but practices will face reductions in Medicare reimbursements if they do not institute the use of such technology.
Health information technology in general is becoming a major expense for primary care facilities.
What Can Doctors Do About It?
Unfortunately, the answer is: Not much. What is really required is legislation that can undo the more harmful parts of the ACA as outlined above, but the chances of such legislation emerging anytime soon are slim.
Until then, doctors must do their best to comply with the ACA’s regulations and find ways to optimize their practices under the new law.
Did I miss any of the downsides of the ACA? On a more hopeful note, do you have any suggestions that may help primary-care practices as they enter a new era of healthcare?
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