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One Bite at a Time: PPACA’s Immediate Impact on Physicians




The answer to the riddle — How do you eat an elephant? One-bite-at-a-time — seems particularly apropos when trying to digest the enormity of health care reform, technically the Patient Protection and Affordable Care Act, commonly referred to as “PPACA” for short, or for our purposes, P-pachyderm.

This legislative behemoth, consisting of nearly 3,000 pages, will grow exponentially over the years, nourished by a constant crop of regulations, which some pundits have estimated could reach 3-million, by the last phase-in period in 2018.

Expanded Coverage Could Mean More Patients

What does this mean to physicians? The first effects soon could be felt as more patients gain health care coverage. For example, people who previously had been uninsured because of pre-existing conditions, now may participate in temporary high risk pools, which serve as a stop-gap until the pre-existing condition exclusion gets phased out entirely in 2014.

On September 23, 2010, group health plans also must extend dependent child coverage to age 26, and may not impose pre-existing condition exclusions (i.e. denial of coverage) on dependents under the age of 19. Group health plans that go into effect after September 23 may not place a lifetime limit on essential health benefits and may only place “reasonable restrictions” on annual dollar coverage limits for essential health benefits.

Persons without coverage generally are less likely to seek treatment at physician offices. Expanded coverage should result in more patients and perhaps sicker patients (if we look at pre-existing conditions as an indicator) visiting physician offices, particularly those of primary care physicians.

Paradigmatic Shift to Preventive Care

PPACA’s impact also will result in a paradigmatic shift from focusing on episodic treatment to emphasizing patient/ family centered care, prevention and wellness. Starting this Fall, many group health plans will be required to provide first dollar coverage, without any cost-sharing requirements (e.g. co-pays or deductibles), for preventive care services recommended by the U.S. Preventive Services Task Force; CDC recommended immunizations; and preventive care for infants, children, adolescents and women provided for in guidelines by the Health Resources and Services Administration.

These effects likely will exacerbate the current shortage of primary care physicians. PPACA hopes to increase the number of primary care physicians by offering bonus incentives. Beginning in 2011 and lasting through 2015, primary care physicians who treat Medicare patients may be eligible to receive a 10% bonus if their Medicare charges for office visits make up at least 60% of their overall Medicare charges.

Still, it is doubtful that the number of primary care physicians will be able to keep up with the swollen demand of patients, which likely will result in greater reliance on mid-level providers, who will seek an expanded scope of practice, as evidenced from recent activity by Ohio advanced practice nurses who lobbied for the elimination of restrictions to their prescribing scheduled II controlled substances under clearly defined conditions.

These are some of the immediate effects of our P-pachyderm’s rumblings. Bigger things lie ahead. Already in place are plans to move toward more robust pay-for-performance and shared-savings models predicated on evidence-based medicine, quality measures and outcomes.

Accountable Care Organizations and Medical Homes could well redefine relationships between physicians and hospitals bringing about greater provider integration, which eventually could lead to the end of fee-for-service, as bundled payments are divvied up among providers.

Greater Scrutiny

With health care reform will come greater scrutiny of physician practices that try to “game” the system. PPACA requires DHHS, by September, to implement a self-disclosure protocol that physicians must follow to report to CMS, upon discovery, actual or potential violations of the Stark regulations’ prohibition against self-referral of designated health services in which they have an ownership or financial interest.

Beginning 2011, PPACA will appropriate an addition $250-million for increased governmental fraud and abuse (kickback) detection and prosecution.

Next Article

By now, you’ve probably had enough P-pachyderm to cause at least mild indigestion. In the next article, we will discuss the profound, long-term effects health care reform will have on the delivery of health care — the greatest since Medicare was enacted in 1965 — which may cause some readers to reach for the purple pills and others to hope that another pack of elephants, ridden by GOP partisans, chases the P-pachyderm into the happy hunting ground.

Joe Feltes and Dustin Vrabel are attorneys with Buckingham, Doolittle & Burroughs. Mr. Feltes is a member of the Health & Medicine Practice Group and is the Managing Partner of Buckingham Canton. Mr. Vrabel is an associate with the Firm.

MD News October/November 2010, Northeastern Ohio-Western Pennsylvania


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