The Affordable Care Act and Physician Assistants

How is the ACA going to affect me as a PA? How is the ACA going to affect my patients?

By: Paul Gonzales

These two questions were posed in an article written in the september issue of PA professional. I think they're both very important questions for pre-PA students, current students, and practicing PA's. If you don't know what the ACA is - the Affordable Care Act is what people are calling ObamaCare. The terms are interchangeable, incase you were wondering. Signed into law March 23, 2010, the ACA quickly implemented changes such as the following below. In addition, the grand impact of the ACA was to decrease the number of uninsured Americans by as many as 32 million people. Highlighted in red are a few impacts that relate heavily to PA practice. I encourage you to read through all of them.

• Cover children younger than 19 regardless of pre-existing conditions (2010)
• Young adults can now stay on their parents insurance until they are 26 (2010)
• Access to insurance for uninsured individuals with pre-existing conditions (2010) - some people who have be uninsured for 6+ months have trouble finding insurance because of existing conditions
• Scholarships and loan repayment plans (2010) - primary care practitioners have access to repayment or loan forgiveness programs to increase the primary care workforce
• Increased federal payments to providers in rural areas (2010)- this includes PA's who work in rural areas; examples are Medicare, Medicaid, Children's Health Insurance Program
• Cover individuals regardless of technical errors on their insurance applications - so insurance companies cannot avoid paying for services when you get sick (2010)
• Regulated lifetime dollar limits (2010) - i.e. people who have long term health concerns and would face massive medical bills once their lifetime coverage limit was reached 
• Regulated annual limits on coverage -  restricted dollar limit use in plans (2010)
• Consumers now have an appeals process for challenging insurance company determinations and denial of claims (2010)
• Small businesses/non-profits get health insurance tax credits (2010)
• Required FREE preventative care for Medicaid patients (2010 and 2013) - forget the copays, coinsurance, or deductibles, these are free-99! 
• Financial relief for seniors on Medicare Part D prescription drug "donut hole" (2010/2011)
• Free preventative care for seniors and improved care after hospitalization (2011) - including annual wellness visits and prevention plans, hoping to reduce readmissions to the hospital 
• Linking Medicare hospital payments to outcomes (2011) - in 2012, hospitals were required to publicly report outcomes for patients treated for heart attacks, heart failure, pneumonia, surgical care, and healthcare associated infections, as well as patients' perceptions of care. If you didn't know this students/pre-PA students, you should check with your hospitals to see what your ratios are like!
• Insurance premium rebates for consumers (2011) - Also known as the "medical loss ratio," insurance companies basically are required to spend at least 85% of premium dollars collected by large employer plans to go toward medical services, and if not, then the excess must be distributed back as a rebate to the consumers
• Testing new strategies for care (2011) - The Center for Medicare & Medicaid Innovation was created out of the ACA to test new healthcare payment and service models, including accountable care, bundled payment models, and many more. I plan on discussing some of these in posts to come. 
• Healthcare providers who work together, make money (2012) - providers who join Accountable Care Organizations (ACOs) to coordinate patient care will be eligible to keep money that they save; this is an incentive for health providers to improve the efficiency of our system - a much needed tactic
• Electronic Health Record Systems (2012) - reduces paperwork and administrative costs, reducing medical errors
• "Bundled Payment Systems"(2013) - Pay attention students! This is a biggie! This program encourages everyone (hospitals, docs, PAs, NPs, other medical personnel) to coordinate care and bill Medicare a flat rate, rather than a fee for service (FFS) system. This means that everyone under the team is held accountable and are required to produce the best results to ensure that the costs do not exceed the flat rate. If they do, then no one will make money, and instead, financial burden may be evenly distributed amongst all groups. If costs are under the flat rate, then everyone can share equally in the profits. 
• Expansion of preventative healthcare to Medicaid recipients (2013) - more funding allotted to states Medicaid programs to provide preventative care to Medicaid patients
• Increased Medicaid payments for PCP's (2013) - Primary care physicians are required to get no less than 100% of Medicare payment rates for primary care services in 2013-2014; PA's are also eligible 

CHANGE COMING IN 2014!

• No discrimination based on pre-existing conditions or GENDER (2014) - no denial of coverage for a pre-existing condition, or cannot be charged higher rates for gender or health status
• END annual limit on insurance coverage (2014) - any new plan cannot have an annual dollar limit on coverage for "Essential Health Benefits"
• Continued coverage for persons in clinical trials (2014) - cannot drop you even if you participate in clinical trials for cancer or life-threatening diseases
• Tax credits to individuals making insurance more affordable (2014) - people with income between 100-400% poverty level not eligible for Medicaid, are eligible for monthly tax credits to lower premiums
• Small business tax credits (2014) - credits of up to 50% of employers contribution to employees premiums - encourages employers to provide coverage to all employees
• Expanded access to Medicaid (2014) - people with incomes less than 133% ($14,000 for an individual, and $29,000 for a family of four) are eligible for Medicaid. The government will pay 100% of coverage for 3 years, then 90% thereafter. 
• Health Insurance Marketplaces Go Live (2014) - individuals and small business are eligible to purchase insurance 
• Individual Mandate (2014) - Requires every individual who can afford coverage to purchase insurance 

CHANGE COMING IN 2015!

• Value, not Volume (2015) - Physicians who provide higher quality care measured by patient outcomes will receive higher Medicare payments than those with lower quality care

So how does this affect you, as a PA? 

For practicing PA's, you may be faced with questions by your patients about health insurance options that are affordable. The ACA also includes provisions that may support you financially such as:

1. Financial support for those who choose to go into primary care in underserved or rural communities
2. If 60% of your services are in primary care, you may receive a 10% Medicare incentive payment for certain primary care services, up to 5 years.

PA's are also integrated in the ACA in other ways, including established team-based care, including Patient-Centered Medical Homes (PCMH), Independence at Home models of care, and Accountable Care Organizations (ACOs). We all know that PA's are a crucial part of the healthcare team, but remember that you are individuals yourselves and you have to take care of yourself sometimes, too. Take care to read on provisions being implemented in 2015 above. Make sure you're working for a physician who is likable by his or her patients and receives positive reviews, because these new reforms could impact patient care practice. Working in rural or underserved areas, including primary care can sometimes mean more money and incentives through federal programs because of the ACA. The expansion of Medicaid will mean PA's are needed heavily in primary care, so expect more job opportunities to pop up throughout the next few years. 

So, why the reform?

• Americans have shorter life expectancies than people in 16 comparable high income countries, and that gap is greater for women
• US has had the highest infant mortality rate for decades past
• Children are less likely to live to age 5 in the US than any peer country
• US has highest obesity rate, with highest rates among children in every age category
• Number of adults diagnosed with diabetes in the US tripled from 1990-2010 to 20.7 million
• US has second highest death rate from ischemic heart disease and among highest rates of lung disease (National Research Council and Institute of Medicine Panel on Understanding Cross-National Health Differences Among High Income Countries)
• In 2010, 20% of Gross Domestic Product was healthcare
• 149 million Americans are dependent on employment-sponsored health insurance - coverage American employers are being outpaced to pay for
• 48.6 million uninsured Americans resorted to emergency rooms when health needs were acute

What can you take away from this? 

The lesson learned here is not to be defensive or cocky about whether the ACA is a "democratic-thing" or a "liberal-thing," but it was designed to be a way to fix the broken healthcare system we have, because the focus of our healthcare system is currently quantity, not quality. Increasing access to healthcare and educating patients while reducing costs in the form of preventative, cost effective medicine is the way of the future. Fact of the matter is - things like electronic health records, health insurance, bundled payments, and the Medicaid system are all topics no one ever wants to discuss because everyone has a different opinion about. We can all agree that each was ready for change and that change needed to happen now so that healthcare can finally move forward.