Supreme Court ACA ruling impact: More patients, little help with costs

The U.S. Supreme Court’s decision today upholding the constitutionality of the Affordable Care Act (ACA) means you will probably be seeing more patients in the coming years, but it does little to control the spiraling costs that are squeezing many primary care practices.

The court said that the linchpin minimum essential coverage provision of the ACA-also called the individual mandate-can be considered a tax, which Congress has the power to impose. The mandate is scheduled to take effect beginning in 2014.

At the same time, however, the court made it somewhat easier for states not to comply with the parts of the law that expand Medicaid eligibility. Nevertheless, the final result of the court’s ruling will be to make some form of healthcare insurance available to many more of the estimated 49.9 million Americans who do not have it.

The court’s decision will be discussed in policy circles for years, healthcare pundits say, but its impact may add an exclamation point to a system in the throes of massive change fueled by escalating costs, fragmentation, and duplication.

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Many doctors believe that private payers are squeezing reimbursements, with the result that many physicians, especially those in primary care, are struggling economically. In fact, 26% of physicians in private practices with 10 or fewer doctors warn that they might close if the financial situation doesn’t improve in the next year, according to a new survey from MDLinx, a medical marketing and research organization. Three in 10 physicians in smaller practices report that 2012 is shaping up to be one of their worst years ever.

By increasing the number of Medicaid enrollees, the ACA may worsen the cost squeeze on primary care physicians (PCPs), says Devon Herrick, PhD, a health economist and senior fellow at the National Center for Policy Analysis.

“Most doctors try to keep a certain ratio of Medicaid/Medicare patients to those covered by private insurance,” Herrick says. “To the degree that more of their patients have public insurance…a lot of doctors may begin to limit or even freeze the number of new Medicare and Medicaid patients they’re willing to treat.”

"I agree that everyone should have healthcare coverage, but at what expense?" asks George G. Ellis, Jr. MD, aMedical Economics adviser from Boardman, Ohio. "The law may end up being cumbersome for PCPs who are already overworked and now are asked to take on additional patients."

The Supreme Court’s ruling could trigger additional momentum for creating new patient-centric models similar to accountable care organizations (ACOs) and Patient-Centered Medical Homes. Such models are believed to help reinvigorate the role of primary care as gatekeeper and offer new incentives to reduce healthcare costs.

“Accountable care…got much more visibility through the [ACA]t,” says Leslie J. Levinson, JD, a partner with the law firm Edwards Wildman Palmer LLP in New York, New York. “Certainly after the Centers for Medicare and Medicaid Services revised regulations, you got a lot more appetite for participating in ACOs. Whether you call it gain sharing, bundling, capitation, whatever the nomenclature is, people are now sitting across the table in a much more collaborative way than they may have been in the past to say ‘OK, how can we really make this work?’ So I think those concepts are just going to get more steam, not less.”

"Value-based or accountable care is at the core of the health reform law," notes Charles Lockwood, MD, dean of Ohio State University's College of Medicine and editor-in-chief of Medical Economics' sister publication Contemporary OB-GYN. "Theoretically, value-based care rewards health systems and health providers that achieve better patient outcomes and contain rising costs. It is far from clear, however, that value-based care will do either. Thus, today's decision will increase access, but it will also increase the cost of healthcare and force fundamental healthcare delivery reform."

Specialists also are affected by the law, although the impact on them is more likely to be felt through the Independent Payment Advisory Board (IPAB), which is charged with developing and submitting proposals to slow the growth of Medicare and private healthcare spending and improve the quality of care.

“The big-ticket items are from specialists-putting a stent in a heart, putting in a pacemaker, using a robot to take out a prostate. What if the IPAB says some of those things are too expensive?” asks William F. Gee, MD, a urologist in private practice in Lexington, Kentucky.

But Matthew Albers, JD, a health law attorney with the Cleveland, Ohio, law firm Vorys, Sater, Seymour, and Pease LLP, disagrees.

“I don’t think most specialists believe, nor do they have any indication to believe, that there will be a huge decrease in demand for their services,” he says. “[The PPACA] might be perceived by all doctors as recognition that incentivizing…physician coordination is an appropriate way to maintain better outcomes and achieve better costs.”

-With reporting by Dan Verdon, Jeff Bendix, Diane Sofranec, Dick Kerr, and Bethany Chambers

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Affordable Care Act upheld; urologists concerned about 'key aspects' of law(Urology Times)

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Court rules for ACA; traveling industry should benefit(Healthcare Traveler)

Medicaid expansion will stand with revision(Managed Healthcare Executive)

Physician organizations react to the Supreme Court ruling on healthcare reform