How well do physicians know the ACA?

Thomas Raskauskas, MD, CEO of St. Vincent's Health Partners in Bridgeport, Ct., knows education is key for prepping Connecticut doctors for impending changes under the Affordable Care Act.

St. Vincent's, a physician-hospital organization, recently developed a program with Fairfield County Medical Assn. that holds continuing medical education events every other month on the status of health system reform. “I have had physician groups and organizations that have been calling me to ask for instruction on what this means for them and their practice,” Dr. Raskauskas said.

Because the ACA involves goals of more patient-centeredness and better care coordination, he said his PHO issued a requirement that its primary care physicians obtain recognition from the National Committee for Quality Assurance to operate patient-centered medical homes. It also developed an educational series on care coordination and the transitions of care “so that our doctors better understand what their role is in each handoff,” he said.

Health system reform is expected to bring significant changes to the health care system, particularly starting in 2014, when millions more will gain insurance cards and have new coverage options through state health insurance marketplaces and expanded Medicaid programs.

Physician organizations anticipate that much of this transformation will be positive. Not only will doctors start seeing more newly covered patients, but they “will no longer need to worry about their patients coping with coverage denials due to preexisting conditions or lifetime caps,” said Ardis Dee Hoven, MD, an infectious disease specialist and president-elect of the American Medical Association. Patients also will be able to see doctors earlier instead of waiting until illnesses progress to the point where care is more expensive, she said.

But although physicians have been hearing since 2010 that things are going to change, some still may not realize that the ACA “is the biggest change we're going to go through” since the establishment of Medicare in 1965, said Peter Anderson, MD, who practiced family medicine for 30 years and is now president of Team Care Medicine LLC, a health care management company in Yorktown, Va.

The overhaul doesn't just add 30 million newly insured patients into the system. It also is testing major new payment reforms, such as accountable care organizations, alignment of pay rates with quality measures and bundled rates, Dr. Anderson said. “It will impact every physician in active practice.”

Physicians do need education on the ACA, and “some are more informed than others,” said Kenneth Schellhase, MD, MPH, who chairs the legislative committee of the Wisconsin Academy of Family Physicians.

Based on what doctors know about the impending changes under the law, some practices have determined that they need to make changes of their own. Christopher Bush, MD, a family physician in the Detroit metropolitan area and immediate past president of the Michigan Academy of Family Physicians, belongs to an independent practice association that operates as a physician-directed ACO. He said his IPA has been getting ready for the ACA's coverage expansions by upgrading its health information technology network so that it has a sophisticated system in each office that better serves the new patients coming into the system starting in 2014.

A focus on insurance exchanges

Some health care observers suggest that to prepare adequately for the ACA, physicians need to know more about what's in it.

The law has been a difficult issue to follow, in part because each state has been making its own decision on expanding Medicaid and establishing a health insurance exchange that allows people to shop for private coverage, Dr. Raskauskas said. Doctors are trying to figure out what all of this means for their practices, the exchanges in particular. One of the biggest misunderstandings physicians have about the exchange issue is that it's just about Medicaid expansion, when it actually involves third-party insurance that's subsidized for some by the federal government based on income, he said.

Physicians should develop a working knowledge of such coverage issues, said Lou Goodman, PhD, president of the Physicians Foundation, a research and advocacy group funded through settlements of physician class-action lawsuits against insurers. As an example, what happens if 30% of a particular physician's patient base is covered by one employer that decides to stop offering insurance and instead pay the ACA's employer mandate penalty? The result would be that many of these patients would end up getting new coverage on an exchange, and the physician may not have contracts with all of the insurers selling products in the marketplace, he said.

Goodman said a long-time patient might say to a physician: “ 'I'm on the exchange now. What insurance company should I go with? I've been with Blue Cross, but United offers me a better price, and I think I want to go with them. Can you still see me?' But the doctor says they don't have a contract with United. Those are the kinds of questions we're going to see once we have this clearinghouse set up.”

The Physicians Foundation has taken steps to break down the 2,000-page health system reform law into categories “so the doctors have a working knowledge of how it impacts physicians in particular. And we're trying to help them translate that and what that means for their patients,” Goodman said.

Still, it's not clear if some of the ACA's central provisions will have that much of an effect on physician practices, Dr. Schellhase said.

Even if the exchanges produced doctor network changes, physicians already are accustomed to “falling in and out of networks in recent years as different insurers negotiate different contracts from year to year,” he said. “It's hard to predict with certainty, as there is so much unknown about how exchanges will work.”

Homework not limited to ACA

Susan Turney, MD, president and CEO of the MGMA-ACMPE, the organization for medical group managers, said administrators of many group practices “are familiar with what's coming down the pike.” They know that they're going to have to figure out how to manage a new influx of patients to their practices and possibly a different payer mix once health coverage expansions take effect. If some of their patients had been insured commercially and now are moving into different plans on an exchange or an expanded Medicaid program, they know this will cause some significant shifts to the practice, she said.

Practices are asking themselves, “How are we going to make sure we keep the doors open?” Dr. Turney said. Practices need to make sure that “the people who are seeing patients can actively do what they do best, while trying to manage with the uncertainty of Medicare and Medicaid payments, and the uncertainty of exchanges.” Doctors still must balance other demands, including learning new diagnostic claims codes under ICD-10, she said. “I can't think of a practice I've spoken to in the last six to eight months that has not had this on their radar screen.”

Dr. Turney said the MGMA-ACMPE has been assisting members on how they should manage their practices if plans on their respective state exchanges pay less than Medicare, and if they would be able to access patients in this model. “Based on the information that we have from a legislative, regulatory perspective, working with the payers, understanding the broader environment, I think that's where we play a huge role,” she said.

The AMA has posted resources online to let physicians know of the changes they will encounter as major ACA provisions go into effect, Dr. Hoven said.

For example, the Association has taken steps to help doctors prepare for the law's Physician Payments Sunshine Act, which had final regulations issued in February. Starting in August, drug and device makers will begin tracking payments and gifts they make to doctors for eventual public release, but a recent survey of more than 1,000 physicians by the health technology company MMIS found that more than half of doctors weren't aware of the act's basic provisions.

Dr. Hoven said doctors should become familiar with the federal government's new Sunshine Act database, “which is being created to ensure that physician relationships with the pharmaceutical and device industries are transparent.” She also encouraged successful participation in the Medicare physician quality reporting system in 2013 to avoid a 1.5% pay penalty in 2015.

Dr. Hoven emphasized that the ACA isn't the only source of major health system changes. Physicians also need to learn about other reform provisions, “including new Medicare payment and delivery models and meaningful use of electronic health records. The AMA has a plethora of resources for physicians as the health care system evolves.”