What's Next in Healthcare Reform?

The Supreme Court has spoken. Here are three reforms that will impact physicians.

By Bill Kekevian, Associate Editor

Now that the Supreme Court has upheld the Patient Protection and Affordable Care Act (PPACA), physicians are sorting out what happens next. Ophthalmologists and other specialists are bracing for curtailed Medicare reimbursements. The law empowers an appointed board to review and set Medicare payment rates in the future. The Physician Quality Reporting System would impose further regulations on practices.

Specialists are Concerned

Specialty doctors express little support for the bill. Some are expecting the Centers for Medicare and Medicaid Services (CMS) to cut reimbursements. Others worry the law is too centered on primary care physicians. “The purported cost savings of the Affordable Care Act are built upon concepts like value-based medicine and accountable care organizations,” AAO CEO David W. Parke II, MD, says in a Web video. “Those, in turn, depend upon steep reimbursement cuts for specialists.”

ASCRS, in a joint statement with other members of the Alliance of Specialty Medicine, committed to advocating for repeal of the law. “We will not be deterred from working to reform or repeal certain aspects of the Affordable Care Act that are onerous to the practice of medicine and are detrimental to patients' access to quality care,” the statement reads.

William L. Rich III, MD, AAO medical director of health policy, shares the concern that the law does not do enough for specialists. “There are some aspects that are bad,” Dr. Rich says. “I have a feeling we still have not done enough to touch the cost of medicine. All the new programs being developed by Medicare will have very little impact on the cost.”

However, Dr. Rich expresses cautious optimism. “It's a positive for ophthalmologists,” he says. “Some people will oppose it for personal political reasons, but most ophthalmologists I talk to say it's the right thing to do.”

In a 5-4 decision, The Supreme Court confirmed the Constitutionality of the Patient Protection and Affordable Care Act.

Medicare Anxiety

“I do have some anxiety about fee-for-service Medicare patients,” Dr. Rich adds. “It's important to the specialty. We derive the greatest revenue from Medicare of any specialty. Medicare is huge for us.”

The charge that PPACA is too focused on primary care has its basis in the law. Last month, Medicare announced a proposed rule to raise payments to family physicians 7% while raising payments for other primary-care services 3% to 5%. The same proposed rule noted that changes in payment calculations “would result in reductions in total payments projected to cardiologists and ophthalmologists.” PPACA itself outlines a 10% incentive payment for primary care physicians and even general surgeons, but makes no such provision for ophthalmologists. However, Dr. Rich noted that CMS has slated a 1% increase in payments to ophthalmology for 2013.

More Insured Patients

Meanwhile, PPACA would expand the rolls of Medicaid beneficiaries. While reports speculate an expansion of between 17 million and 30 million new beneficiaries, what's for certain is every individual under 65 with an income below 133% of the federal poverty line would be eligible for Medicaid.

Extending health insurance coverage to millions of new beneficiaries will have an impact for physicians, Dr. Rich says. Too often, he suggests, ophthalmologists in subspecialties such as pediatric ophthalmology do not get reimbursed for their care of uninsured patients. As PPACA rolls out, those doctors can expect to see more patients able to pay. “That aspect of upholding the law is a real plus,” he says.

Individual states, however, will determine how that Medicaid expansion is enacted within their borders. Some conservative lawmakers, Texas Gov. Rick Perry among them, have vowed to strike down the expansion, while other states, such as California, have embraced it. In Los Angeles County alone, 80% of the 2.2 million uninsured will be eligible for the state's Medicaid program under PPACA, according to the Los Angeles County Department of Health Services.

Understanding IPAB

Under the new healthcare law, the 15-member Independent Payment Advisory Board (IPAB) will be tasked with making payment policy for Medicare. Secretary of Health and Human Services (HHS) Kathleen Sebelius has said the board will help control costs, but groups such as ASCRS insist that without reducing patient benefits, the board will end up reducing physician reimbursements. One of the many charges levied against this board is that it will end up rationing care. HHS is adamant to dispel that claim and points to a provision expressly prohibiting the board from making that sort of recommendation.

IPAB will have authority to set the rates for Medicare payments. Unlike the Medicare Payment Advisory Commission, which advises Congress on Medicare payment issues, IPAB's decisions would be binding.

The law's critics, notably ASCRS, frequently refer to IPAB as a board of 15 “unelected, unaccountable members appointed by the President.” The Medical Group Management Association (MGMA) has also advocated for the repeal of IPAB. “It creates uncertainty,” says Miranda Franco, MGMA government affairs representative. “It makes it hard for small businesses to make decisions.”

The law itself stipulates IPAB members should include, but not be limited to, physicians and nonphysician healthcare professionals. It also calls for a system of public disclosure in the interest of preventing conflicts of interest.

IPAB's payment recommendations would be influenced by prevailing trends, Ms. Franco says. For example, if IPAB determines overutilization of Medicare services, the panel could impose reimbursement cuts. “We're looking at a series of cuts already,” she says. “The IPAB could mean more cuts.”

Managing PQRS

The Patient Quality Reporting System currently rewards doctors for participating in the voluntary system, but will soon penalize those who do not. Under PQRS, participating providers will receive a bonus of 0.5% of total Medicare receipts through 2014. However, in 2015, nonparticipating physicians will see penalties of 1.5% of Medicare payments and by 2016 they will be up to 2%. Five PQRS measures are specific to ophthalmology and at least two others are relevant (TABLE).

For the time being, physicians can collect benefits by reporting one of four ways. The CMS provides a downloadable decision tree on its Web site to help physicians determine which approach best suits their needs. Information may be reported to CMS using Medicare Part B claims or to a qualified Physician Quality Reporting registry. Doctors may also report to a qualified Physician Quality Reporting data submission vendor or via qualified electronic health record products.

To those skittish about the uncertainty of new regulations, Dr. Rich says not to worry. Ophthalmologists will actually be rewarded for demonstrating “better quality outcomes at reasonable resource use,” he says.

“Those of us who have higher treatment costs for a population of patients will have our access to patients restricted,” he says. “One, don't be afraid to be measured. We have wonderful surgical outcomes with high patient satisfaction when compared to other specialties. Two, don't do unnecessary testing because that is being measured now and will be used to restrict access to you for commercial and Medicare patients in the future.”

Harmonization

Ms. Franco says PQRS is already in need of reform, at least in one aspect.

The problem, she says, is that the healthcare law has made participation in PQRS no longer voluntary. That's a break from its predecessor, the Physician Quality Reporting Initiative.

“We've long advocated against penalties,” she says. Confusing and unnecessary layers of bureaucracy and paperwork are bad for business, she says. For example, while the penalties go into effect in 2015, they correspond to the 2013 performance year.

“PQRS is, by no means, a perfect system,” she says. To combat this murkiness, MGMA says it is helping members with issues of reporting measures and deadlines. The organization is also putting members directly in touch with CMS and urging CMS representatives to respond to doctors.

“I don't think there's a one-size-fits-all approach, but I think people have accepted this is the direction,” Ms. Franco says of the eventual implementation of the PPACA. “Instead of focusing on how we can change or repeal, we want to focus on how we move forward.”

For MGMA, moving forward means influencing lawmakers to develop greater “harmonization” of various reporting programs. As it stands, e-prescribing, PQRS, EHR, etc, all require separate reporting data. MGMA states that the process should be streamlined. OM