Friday, April 6, 2012

Overturn the ACA, and chaos will follow

Imagine you’re a physician, and you have a full schedule of patients to see the day after the Supreme Court has thrown out the entire Affordable Care Act. Imagine you never liked “Obamacare” in the first place, so you are feeling pretty good about the Supreme Court decision.

Your first patient, an elderly retiree named Mrs. Jones, comes in for her annual Medicare wellness visit—one of the new Medicare preventive benefits offered at no cost to the patient. But this new preventive service benefit was created by the ACA, so presumably with the ACA overturned, Medicare no longer is allowed to pay for wellness visits. Do you tell Mrs. Jones that Medicare might not cover the visit? Provide the visit anyway, hoping that somehow Medicare will find a way around the Supreme Court ruling and pay for it? Offer it at no charge, or try to collect the 20% you would collect for a normal (non-preventive) office visit? 

Your second patient, Mr. Jones, another senior, comes in for a follow-up visit for an ongoing chronic condition. You decide to renew his expensive brand-name prescription drug, knowing that he is eligible for a 50% discount because he has fallen into the Medicare Part D “doughnut hole.” Oh wait ... the Medicare Part D drug discount was part of the now-defunct ACA. So does that mean he now has to pay full price? Do you prescribe the drug anyway, knowing he can’t afford to pay the regular retail price? Prescribe a lower cost no-name brand drug that he doesn’t tolerate as well?

Your billing person prepares to submit the claim for Mr. Jones’ office visit. It ordinarily would have been eligible for the 10% bonus that Medicare pays for all office visits, nursing home and custodial care visits provided by primary care physicians. But that was before the Supreme Court overturned the ACA, and with it, wiped out the primary care bonus created by the law. With the bonus gone, your practice will lose about $4,000 over the next six months. Does the bonus disappear immediately—with this visit? What happens to bonus payments that were already paid out? Who knows?

Next up is Ms. Wilkins, a single mother of three who is seeing you for her diabetes and congestive heart failure. She is fortunate enough to be among the 50,000 Americans enrolled in the low-cost Pre-existing Condition Insurance Plan created by the Affordable Care Act and administered by the state. Oh wait, that was until the Supreme Court decision. With the ACA gone, the authority and funding for the Pre-existing Condition Insurance Plan disappears. Will she still be covered for this visit and any tests or medications she needs? And if so, for how long before the program is forced to shut down? Where else will she find affordable insurance? Will she go without it? Who knows?

A text message comes into you from your 22 year old son, a recent college graduate who hasn’t found a job. He has a doctor’s appointment for the knee he hurt playing rugby, and wants to know if he still will be covered by your health insurance plan. But the requirement that young adults up to age 26 be covered by their parents’ plans was part of the ACA, so presumably, your health plan no longer is obligated to keep him. Will it drop him? If it keeps him on, for how long, and for what extra premium? 

You start thinking about your oldest daughter, a fourth year medical student who plans to apply for a loan repayment program from the National Health Services Corps in exchange for providing primary care in an underserved community. But the funding for NHSC in 2012 comes entirely from dollars mandated by the ACA. Will the NHSC now have to cut back on its award amounts and recipients? When, and by how much? Will she no longer be able to get a NHSC slot?

Your practice has joined with other primary care physicians in the community to become an accountable care organization (ACO) under the Medicare Shared Savings Program. It has spent tens of thousands of dollars and countless hours to do the planning and set up the infrastructure to qualify. But the federal money to pay for the Shared Savings Program comes from funds obligated by the ACA, so with the ACA gone, the ACO program may be suspended as well. Does that mean your practice wasted all of that money preparing to become an ACO?

Your local medical school has applied for Title VII primary care grants for faculty and scholarships for low-income students—the only federal program specifically designated to support primary care training. But the Title VII grant program was part of the ACA. Does that mean that the grants will be suspended? Who knows?

Your hospital expanded its internal medicine residency program because of a provision in the ACA that redistributes unused residency slots in other specialties to primary care. Who will pay for them if Medicare can’t? Will the slots have to be eliminated?

I could write pages and pages more of programs created by the ACA that would be invalidated if the Supreme Court overturns the whole law. What I can’t tell you—what no one can tell you—is how the federal government will deal with the absolute chaos that will follow.

Rules will have to be withdrawn and re-written, contracts suspended, agencies closed down or downsized, agreements renegotiated, delivery reform pilots terminated or scaled back, and mandated insurance protections suspended—with little guidance from the Supreme Court or Congress on what to do next. And there’s almost no chance that Congress will step in to repair the wreckage.

In the meantime, physicians and patients will be left reeling by the resulting chaos and confusion created by the court’s decision.

I haven’t even mentioned the 32 million Americans who would have gotten coverage in 2014 if the law was sustained—but will lose the most if the court overturns it. 

Henry Aaron, a renowned health care expert at the Brookings Institution, also predicts chaos if the Supreme Court overrules the law:

“And what if the Supreme Court throws out the whole bill?

That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago: with higher costs, more uninsured and a political atmosphere poisoned by the failure of an all-out effort to reform a health care system everyone knows is flawed.

Health insurance costs, driven by the steady march of new technology and population aging, will claim ever larger shares of our income. Those higher costs will make health insurance unaffordable for more and more people.

It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole.

Is that the future we want?”

Today’s questions: What are you going to do to prepare for the chaos that will happen if the Supreme Court overturns the entire Affordable Care Act? Is that the future we want?


Bruce said...

Very thoughtful and nicely done!

ryanjo said...

Bob, you are really getting very gloomy, now that your favorite law is in danger!

Of course, none of these scenarios will happen. These programs all are active now, funded by the alleged 500 billion dollar reduction in Medicare "waste & fraud". In addition, any reductions that the President may try to make will be blunted by a hostile Congress in a contentious election year, in which seniors are valued voters.

And as far as the uninsured millions, regrettably they will not be offered the pitiful pittance called Medicaid if the individual mandate is reversed.

Convinced yet that government is an unreliable partner in health care reform?

BDoherty said...
This comment has been removed by the author.
BDoherty said...

RyanJo , I must respectfully correct you on the facts. All of the consequences I mentioned in my post WILL happen because they are ALL programs created by the ACA and funded by it. If the ACA is overturned, every single part of it goes with it This isn't a case of the President deciding which parts he would keep or not. If there no longer is any law on the books to allow Medicare to pay for services like preventive benefits because the Suoreme Court overturns the ACA, the President and CMS cannot continue to pay for things or enforce laws that no longer exist. The $500 billion in Medicare savings used to pay for these benefits also disappears if the ACA goes. Physicusns and patients had better be ready.

ryanjo said...

And I must disagree with you, Bob.

The Supreme Court will need to decide whether the entire ACA is unconstitutional, or only the individual mandate, or the Medicaid extension opposed by 26 states as a coercive expansion of federal authority. The Court will decide if the other parts of the law (including popular provisions) can survive without the mandate provision.

None of these questions have been answered with certainty. The Obama Administration has taken up "the sky is falling" approach, predicting disaster. The Republican chairman of the House Commerce Committee says they will replace favorable health care law provisions if the Supreme Court strikes down any significant parts of it.

None of these scenarios approach the threat that the looming SGR reductions pose to physicians & patients.

Health care chaos is likely to continue for years, whatever the Court decides. The task for organized medicine is to untangle the basic physician-patient relationship from government interference, not entangle it more deeply.

PCP said...

The people of this country are resourceful and will find ways to make out just fine.
All the scaremongering in the world will not change one simple fact. This law destroys the primacy of the doctor patient relationship and interposes the gov't in its midst.
The country did just fine when doctors and patients were contracting with each other and they can continue to do so if the law is thrown out.
Each of the provisions if desirable to the people and congress can be enacted separately.
Seniors can decide for themselves if an annual preventative visit is worth paying for out of pocket and cms can decide if the investment on the front end is worth it for them as risk bearers. Doctors and patients figured out which medications to use and the costs BEFORE medicare D entirely and are easily capable of doing the same again. Guess what bob, we can figure out ingenious alternatives.

The cms can redirect gme funding, if they so desire. Since the republicans are on record as supporting removing the use of preexisting condition discrimination on coverage, a patch is doable, if the public wants it they will demand it and last I checked we are still a representative democracy. Ditto coverage for the under 26 age young adults on their childrens policy

The pittance that is the 10% primary care bonus, is the equivalent of a baby aspirin to ease the pain of a terminally ill cancer patient. Something that will have no meaningful impact on the problem.

Anything that kills the support for community health centers and federally qualified health centers etc. such as NHSC loans and instead encourages financially independent physician practices in its place would be the best solutions. We ought not to create a void by killing independent practices and replacing them with heavily subsidized and expensive gov't programs like CHCs and FQHCs. Incentivize private practice doctors and they will provide the services needed there more efficiently that those entities. No need for federal loan repayment policies, thank you. We are proud doctors, we do not appreciate our profession being turned into beggars at the feet of the federal gov't.
Most practices are waiting to see the outcome of this ruling before looking into ACOs and Medical homes. When you lead the herd, you either get the greenest grass or you get eaten, such is life.

No Bob. We are not at all bothered by all you have written. The ACA was never truly meant to help doctors. It weakened my profession when my profession needed strengthening the most. It stabbed us when we were weakest, weakened by decades of gov't imposed regulation, coupled with insurance oligopolies and the AMA sponsored RUC and its RBRVU system.
It treats us not as professionals worthy of leadership and respect and request of us imaginative solutions, but as unworthy self serving disposables, needing more control and regulation.

We welcome peoples ability to choose freely. We embrace freedom. Give us health savings accounts and high deductible health plans. Let the first 5k/yr of health care transaction be completely free from gov't interference or insurance involvement and then you will see the true resurrection of Primary care.

Lets see what happens. Of course we know where the ACP has bet all its chips.

Jay Larson MD said...

PCP highlights good points. No matter what happens, people will adapt. People managed through world wars and people managed through a major depression and they will manage thorough whatever the Supreme Court decides. The demise of private practice outpatient general internal medicine has been a tragedy and recovery is grim at best even if the ACA is left intact. Those of us in the trenches continue to soldier on despite the obstacles until we are felled by the system. There are no replacement troupes. Yes, the sky truly is falling.

Jeffrey Jaeger said...

Bob et al,

I agree that your post paints an unnecessarily gloomy picture. We had a life and a practice in medicine before the ACA -- and if it is deemed unconstitutional, we will find a way to soldier on with whatever comes next. Of course there will be some chaos -- but writing rules, adapting to SCOTUS rulings, revising procedures -- this is what Congress is paid to do.

I believe strongly in the role of government to promote universal access to a minimum standard of healthcare. I believe strongly in the preventive role played by primary care. I do not believe that reimbursement patterns which serve so many in our community (Big Medicine, Big Pharma, Big tech) will change without government intervention. So I am a big government liberal who supports many of the components of ACA.

But if the SCOTUS says it is unconstitutional, so be it. That's the way our system works. We will adapt and move on. The sky is not falling. We will continue to work on crafting a just, viable, sustainable medical system that serves the most people in the best way possible with or without the ACA.

Harrison said...

It doesn't pay to speculate.
The Justices have already made their decisions, and will spend the next several months writing their opinions/rationalizations.

Hopefully they will be convincing whichever way they rule.
The credibility of the court is one of the things at stake in this debate -- but it matters more how they justify their decision than what decision they make.

The next step after the decision is a return to the political debate.
If the court decides to uphold the ACA, then the Republican nominee will have the strong political issue on his side of repealing the law. That rallying cry will get many conservative voters to the polls.
If the court strikes it down, then the Republicans lose that issue but they can make the case that the political strategy of keeping the court conservative is important, and that defeating the President is integral to that strategy. It isn't as strong of a rallying cry but in a bad economy it may work.

From the point of view of day to day life and improvement in our health care environment for patient and physicians, I think that the loss of the ACA will be bad.