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Doctors & the ACA
For all the complex debate about health reform policies, the massive changes to health coverage provided by the Affordable Care Act still pay off in their most tangible form at the simple moment when a provider sits down with a patient.
Many health care professionals in Colorado say that viewed through that standard, the ACA brought some positive changes to the health care system. Yet many in the same group also have a laundry list of improvements.
More and more health encounters are paid through systems that reward primary visits, preventive care, longer conversations and whole-life assistance which don’t always come with a traditional billing code.
At the same time, many Colorado primary and specialty offices are buried in demand, raising questions of how much true change coverage can bring if it doesn’t result in access to actual care.
“Now providers can focus on quality rather than volume,” said David Watson, MD, chief medical officer with Centura Health Physician Group, which represents a network of nearly 500 medical providers employed directly by Centura, the largest hospital system in Colorado.
More than ever, a doctor’s performance is measured from a patient-centered perspective.
“The way that processes are starting to be incentivized is by rewarding for outcomes based on value, effectiveness, satisfaction, convenience, rather than how fast you can keep running on the treadmill,” Watson said.
Those new relationships can certainly benefit the patients who get in the door, said Liz Stark, RN BSN, executive director with Community Health Services, a nonprofit that collaborates with the Colorado Department of Public Health and Environment, Pitkin County and the City of Aspen.
The ACA is a “good start,” Stark said, and has been especially helpful for people who previously had no insurance coverage – people who were excluded from so-called things like “free” wellness checks.
But the word “affordable” in the ACA still does not apply in every patient case, she added.
“We need some regularity regarding affordability because a lot of people still cannot afford [insurance].”
That’s true whether you use Medicaid or qualify for a health plan under the ACA, said Ken Cohen, MD, chief medical officer with New West Physicians, one of the largest private practices on the Front Range.
People who end up with Medicaid, which could be an employed single mom working at the deli counter or a struggling family where dad works seasonal jobs, see their options translate into fewer choices, Cohen said.
“So if physicians are not taking Medicaid, a lot of patients don’t have access to a large subset of physicians,” he said, adding that patients aren’t usually thrilled when their provider pool shrinks.
“Our practices are pretty full, so we made the decision that any of our patients that end up on Medicaid as a function of signing up on the exchange, we would continue to care for them in our practices,” he said.
However, the practice is not able to accept new Medicaid patients – something Cohen said could cause future access to care issues for patients.
“There’s an even greater issue … for Medicaid patients at the specialty care level,” he said.
If someone needs surgery to mend a broken wrist, from, say, a snowboarding accident, Cohen said finding a surgeon who takes Medicaid patients may present challenges.
Communities in Need
Demand and supply issues in Colorado change as fast as the elevated terrain. While Aspen is a charming mountain community to outsiders, on the interior, Stark said, both primary care and specialty care physicians are in short supply. The typical tourist experience of health care is radically different than that of residents who make the local service economy run. In Pitkin County, with the exception of one pediatric practice, none of the primary care or specialty doctors provide services for people on Medicaid.
Many workers travel about 20 miles outside of town to Mountain Family Health Center, a federally qualified health center that takes both Medicaid and private insurance. MFHC provides medical, dental and behavioral health services.
Aspen and the Roaring Fork Valley do have a public transit network supporting both ski tourists and employees; still, for elderly people or young families with small children, Stark said, trekking up and down the valley by bus is no easy feat.
That’s one reason why she’d like to see a satellite health center built within city limits – a solution she said would increase access to care. The health board will review such considerations later this summer, she adds.
MFHC is “at capacity. They need more space and more funds to meet demand,” said Stark, an assessment echoed by MFHC officials.
Stark says the demand at MFHC has increased as a result of the Affordable Care Act providing insurance to more people, through both the exchange marketplace and expanded Medicaid. And that’s a welcome change, she noted. But the coverage will not make a big difference in peoples’ lives, she added, if provider scarcity makes it impossible to either land an appointment or travel to it.
The Always-Future Promise of EHR
One bedrock promise of health care reform has been a transition to electronic health records, bringing the vast paper warehouses of patient files and doctors’ notes into the digital era. The ACA and the HITECH Act provided bonuses to offices setting up electronic records, and a second round of payments to systems that managed to communicate smoothly with each other.
Four in 10 hospitals are still not using even a basic EHR system, Vox health writer Sarah Kliff said in May; only 14 percent of doctors nationally said they could transmit medical records outside their own practice or organization.
Those practices that do set up EHRs are not guaranteed entry into a cohesive system, either. Physician Health Partners, a management group for a wide network of Front Range practices, said its various offices are working on 18 different EHR platforms.
New West spent $3 million on a comprehensive digital record system before the ACA was fully implemented, and still considers the switch a good decision.
The dollar figure is less, but the difficulties greater, in smaller doctor offices across Colorado. Jim Kennedy, MD, and his daughter, Kelley Glancey, MD, who together are the sole providers for their Byers Peak Family Practice in Grand County. Kennedy said it costs about $7,000 per year to have a patient portal, electronic prescribing, and electronic filing maintenance. The sheer cost of EHR can hurt any practice, said Kennedy, but it tends to hurt a smaller practice out of proportion.
Kennedy said a recent breakdown in his practice’s system lasted two weeks. Even on a normal day, the demands for vast amounts of information inputs, and lingering questions over how all that information gets used, still trouble him, he said.
Projects with Purpose
One lesser-known ACA tool helping some providers broaden and deepen their services is the Comprehensive Primary Care initiative, a four-year demo project created by the Centers for Medicare and Medicaid, under provisions in the ACA. Primary care practices are given tools and incentives to keep better tabs on patients with chronic diseases like diabetes – one of the most costly diseases. Translation: Better disease management equals cost savings.
You get paid to treat someone with a broken leg, but also you are rewarded for your efforts when tracking down patients with chronic disease who need repeated refills to help manage a chronic condition like diabetes.
The aim of CPC is to select various primary care practices within seven regions of the United States, and offer innovative payment reform options that help providers deliver high-quality care at lower costs. The program uses a multipayer approach that includes both private and state health plans.
Banner Medical Group in Northern Colorado operates nine locations under the CPC initiative, said J.P. Valin, MD, chief medical officer of Clinical Practice and Western Region for the group.
“The biggest benefit of CPC: It pays a case management fee, a per member/per month payment to our practices for CPC patients in the clinic,” he said.
The extra money allows providers to apply those funds to staff who then work with patients in a coordination of care role – which includes helping with referrals, setting up follow-up appointments and basically “navigating the health care system,” said Valin.
“We’ve embedded clinical pharmacists into our clinics which allow patients on multiple medications to navigate complex medication regiments,” he said.
And in some cases, the pharmacist has minimized duplicative medications, he added.
But not all practices have extra support staff. At their Grand County practice, Kennedy and Glancey do it all, from scheduling an appointment to diagnosing a swollen appendix.
Kennedy referred to CPC as a “blended payment model,” where physicians operate as a fee-for-service provider but also get reimbursed separately for add-on services that treat chronic diseases. Essentially, add-on services stretch beyond typical doctor visits, said Kennedy. It’s this kind of coordination of care that he said would not typically be covered in a traditional fee-for-service model. Even without extra staff, the CPC model allows Byers Peak to improve the patient experience.
“You get paid to treat someone with a broken leg, but also you are rewarded for your efforts when tracking down patients with chronic disease who need repeated refills to help manage a chronic condition like diabetes,” Kennedy said.
Also, under CPC, providers can more easily stay in contact with their patients. And when they make the no-show list, as patients often do, Glancey picks up the phone to reschedule the missed appointment.
Do Physicians Feel Passed Over by ACA?
There is a sense in talking with some physicians that while they recognize the ACA has made some improvements to the overall health system, they do not see it as a piece of social reform that greatly impacts their practice of medicine. More patients come with at least minimal insurance coverage, but that may only add to the paperwork burden of most practices; EHRs have been costly, time-consuming and isolated rather than integrated; case workers can help patients navigate the system, but the doctor’s time always manages to get filled back up.
Cohen, for one, is not holding his breath that the 2016 presidential election will change the direction of national health policy.
“The only thing that will allow meaningful reformation of our health care system is campaign finance reform,” Cohen said.
“Because as long as special interest groups can write legislation, things are not going to move in a direction that helps patients.”
This article was originally published in the Summer 2015 issue of Health Elevations.