An Affordable Care Act Idea

healthcare reformMy Comments: Based on my background in economics, finance and a professional interest in health insurance, on balance I have strong, positive feelings about the Affordable Care Act. Here is one reason why.

Our culture has evolved to where instant gratification is in high demand, to where there is an assumption that any solution more sophisticated than the last one is by definition a better solution, and a real concern that more and more regulation is not helpful.

Health care costs and best outcomes have been going in opposite directions for many years. As a professional observer, the trend lines had to be reversed. I had, and have, no hope that they will be reversed if the landscape is left to corporate America in the form of drug manufacturers, the hospital industry and/or the insurance industry. Their bottom line trumps what is in our best interest as a society.

Buried in the Affordable Care Act was a strategy to improve the financial outcomes for physicians working in the primary care arena. In the near term, some of it may come at the expense of specialists. Over time, if there is financial pressure on specialists and a corresponding financial incentive for primary care docs, then we will slowly move toward preventive care and away from trying to keep people alive at any cost. This long article by THirt, an MD practicing in Ohio, explains some of this.

THirt – Oct 27, 2013

Most people are aware of the main provisions of the ACA: elimination of pre-existing conditions, kids allowed to be on their parents’ insurance until age 26, coverage without cost for preventative healthcare, expansion of Medicaid for states willing to accept billions of dollars from the federal government, and of course, and its insurance exchanges.

However, there is a smaller part of the ACA that has potentially far-reaching effects on all of primary care, and I’ve hardly heard a thing about it in the media. It is helping primary care physicians transform how we deliver care to our population of patients and it is actually kind of exciting.

Read on if you’re interested in hearing a little more about the Comprehensive Primary Care initiative that just might save lives, provide better care, increase satisfaction for patients, doctors and their staffs, and might also, gasp, save a bunch of money.

For a brief piece of background, I am a family practice physician in a multi-specialty group of about 60 doctors, mostly primary care.

I think most people would agree that the American healthcare system has a lot of flaws. One of the biggest flaws is our fee-for-service system in general. It doesn’t make any sense, but I get paid the same to see someone for an ear infection as I do to see someone with high blood pressure, high cholesterol, and diabetes.

Someone comes for an appointment, and based on the level of detail I obtain in the history, the level of detail needed in physical examination, and the complexity of medical decision-making, that determines the fee for the visit. So as you can imagine, an ear infection or sore throat requires a LOT less work than managing three or more chronic problems, and the medications, labs, monitoring tests, etc. that go along with them. But again, you are paid the same to see the ear infection patient as you are to see the person with uncontrolled diabetes, high BP, and high cholesterol.

On the surface, that makes no sense at all, but the thinking is that it probably costs too much for the ear infection, too little for the diabetes/BP/cholesterol patient, but it all evens out in the long run. The rules for ‘coding’ a level of service for an appointment govern the fees, and they are relatively simple, as otherwise it would just be too complicated to have a different fee structure for every diagnosis. Anyway, the idea is that it all comes out in the wash. That might be true in a simple world, but of course we live in a complex world with a lot of moving parts.

As you can see, the fee-for-service environment does not really incentivize physicians to focus their efforts on chronic disease management. I’m not implying that physicians are not trying to do a good job or are just in it to make as much money as possible, but let’s face it: if you make the same amount per patient, and you can see 30 patients with ear infections or 15 diabetic/hypertensive/hyperlipidemic patients, which would you choose? How would you set up your schedule?

Everyone agrees that prevention is the most cost-effective way to keep people healthy. Vaccines, for example, are arguably the single most cost-effective thing in all of medicine (get your flu vaccine if you have not already done so, by the way!). Preventative care is now covered without a co-pay because of the ACA. That is awesome. However, better care/control of chronic disease doesn’t pay well, as discussed above. But better control of diabetes, of BP, of cholesterol, of COPD, of asthma, of heart failure will save lots and lots and lots of money in the long run because complications of all these diseases are expensive. It costs a LOT to be in the hospital, to have a heart bypass, to have dialysis, etc. A rough estimate is that a well-controlled diabetic costs the system an average of $4,000 per year to take care of, but an uncontrolled diabetic will cost $16,000 or more. So why would we pay doctors the same for an ear infection as we would to take care of serious chronic disease?

Part of the answer unfortunately is that people switch insurances and by the time they develop more significant complications, they are on Medicare anyway, so UHC, Humana, Anthem don’t need to worry about paying for dialysis. In the long run, though, it saves us all money if we do a better job of taking care of chronic illness. So it makes sense to try to incentivize doctors to improve our chronic disease management instead of incentivizing doctors to just see as many patients as possible in the day.

So enough background. Here’s the good stuff. The ACA provides funding and guidance for a new way to approach health care. The Comprehensive Primary Care initiative is a program that involves about 500 practices across the country, in several geographic areas. Southwest Ohio/N. KY, New Jersey, Arkansas, Colorado, New York, Oregon, and Oklahoma have participating practices. Practices were selected based on a number of factors, including past willingness to participate in such things as NCQA quality recognition, and patient-centered medical home (PCMH) certification. You can read more here:…

Basically, CMS (center for Medicare and Medicaid services) provides funding outside of the fee-for-service environment for practices to do a better job of chronic disease management. There is/was a detailed application process, and multiple milestones you have to meet, but a lot of it boils down to CMS providing additional monies for practices to use as they see fit in order to help improve the care for their patients, particularly (although not exclusively) those with higher risk chronic illness.

The whole thing is actually really interesting. While there are quite a lot of specifics, there are also a lot of areas open to interpretation. CMS is partnering with multiple private insurance carriers to provide a monthly fee (outside of any appointment or fee-for-service interaction) to physician practices in order to help those practices invest in infrastructure which will help improve patient care. The amount per patient per month is based on risk assessment. Basically, the more diagnoses, and the more complicated a patient is, the higher the monthly fee. A well-controlled diabetic would have a lower fee than a diabetic with chronic kidney disease, heart disease, and neuropathy. So right off the bat, you can see how this is a paradigm shift from the traditional fee-for-service environment. You may actually be paid more to take care of a more complicated person and try to keep them out of the hospital.

However, and this is a BIG part, the money from this CPC initiative can NOT be paid to physicians as compensation. It is to be used to improve infrastructure. This is actually pretty cool because instead of just paying doctors more and saying, “hey, if we pay you more, you’ll do a better job, right?”, CMS is saying, “we will give you money to use as you see fit (within the structure of our program and its milestones) to improve patient care which should improve outcomes, decrease severe complication rates, improve patient satisfaction, and eventually decrease overall costs through an investment up front.”

If you hadn’t already guessed, my group has several practices involved in the CPCI program and we are excited about it. I don’t know what the other 490-some practices across the country are doing, but we have used the money to hire more staff, including what we call Care Coordinators for each office, an RN who can reach out to patients before, during and after appointments to see how we can better coordinate care. We try to have labs drawn before folks come for appointments, so we can have already reviewed the results before walking in the room. This allows for more efficient care. If someone’s cholesterol is the goal, for example, we can increase the dose of their cholesterol medication while sitting with them and explaining why an LDL goal of under 70 is the target. This works a lot better than a medical assistant calling someone and playing phone tag three days after their appointment to try to make sure they know that the new dose is 40 mg instead of 20.

Anyway, the Care Coordinator can help reach out to people who might need help paying for meds and see what assistance programs might help someone. She can help someone who was recently in the hospital understand their new medication regimen and help set up their follow up. If someone doesn’t go for the colonoscopy or mammogram that we ordered, she can call them and find out why and/or encourage them to go (and maybe mention that preventative care is covered 100% now!). She can review their chart ahead of time and put in a reminder for the doctor that the patient is due for a pneumonia vaccine or a shingles vaccine. This is all part of the team-based approach to care which is helping to improve patient outcomes. Our practice would not really been able to afford a Care Coordinator without the CPCI monies. Our group has also decided to hire a diabetes educator. Insurance is often squirrelly about paying for diabetes education, despite study after study clearly showing the benefits. Now we will be able to offer diabetes eduction free of charge to all of our patients. This is pretty great all around. The doctors get more help, the patients get more individualized attention and care, outcomes improve, which specifically means someone didn’t have a stroke. Someone didn’t lose their vision because of diabetes. Someone had a precancerous colon polyp removed instead of being diagnosed with metastatic cancer a couple years later. Someone’s grandmother didn’t lose her foot. Oh, and all that stuff also saves money.

That’s the other piece of the CPCI, which is a multi-year venture: “shared savings.” You can calculate how much a population of patients is likely to cost over say, three years, based on how sick they are. If people get their blood pressure, cholesterol, blood sugar, asthma under better control, they will cost less to take care of because they will have fewer ER visits, fewer hospitalizations, fewer procedures. Sure, they might take more medications, get more frequent lab tests, maybe more frequent (outpatient) doctor appointments, but this leads to an overall reduction of the cost of care. So for the additional work to do a better job of taking care of patients, practices in each region get a chance to share in the $$ saved by providing more efficient care. This will be calculated and distributed equally among the 75 or so practices in each region.

There’s of course a lot more to the story, but this diary is already rather lengthy. I’m excited about the program though. It really is a win-win. It has a lot of the things that us progressives like: government-initiated innovation. Science-based (or to use the medical buzzword, evidence-based) care. Regulations on how the money can be used, with the greater good in mind. Short term investment for long term success (I didn’t mention that the money is eventually phased out with the hope that the infrastructure improvements will lead to overall better reimbursements, and a focus on “pay-for-performance” or better pay for better quality care). Using government dollars to help those who need it most (ie sicker patients). Shared benefits in the long run for all of us. If we are all healthier, we cost less to the healthcare system. We are more productive workers. We have fewer people on disability. We end up putting more $$ back into the economy and indirectly increase government revenue (if you can work more and make more money because you are healthier, you end up paying more taxes and of course can purchase more goods and services).

Anyway, it’s a relatively small part of the ACA, and unless you go to a practice involved in the CPCI, you likely would never hear about it. But in the long run, the idea is that the extra $$ will help to transform how we provide care, therefore leading to a sea change in primary care across the country. If you get better outcomes, improve patient satisfaction AND save money while practicing a certain way, every practice is going to want to adopt these methods. Over the next few years, the 500 practices will be sharing (HIPAA-compliant) data, successes and failures, to try to come up with “best practices” we can all use to keep people healthier longer. Because everyone benefits from that, and that is really what the Affordable Care Act is about.