With the Supreme Court's June 28 decision to uphold the Affordable Care Act (ACA) as constitutional (albeit with some restrictions), the road is more or less clear for the implementation of all the provisions of the act: state-based health insurance exchanges, an end to lifetime caps on coverage and limits on coverage for those with pre-existing conditions, and a variety of other measures that are predicted to bring some 30 million more people under the umbrella of health insurance within the next several years.
This is, for the most part, a very good thing, said Elaine Jones, MD, chair of the AAN Government Relations Committee. Because there were elements of the ACA that it found troubling, the AAN did not take a position either for or against the law, but stated that overturning it likely would have caused chaos.
“A lot of work has been put into implementation already, so it would have been a mess if they had to start over again,” Dr. Jones observed. “Here in Rhode Island, for example, we've spent a year already working on developing our own exchange, and it could have been a real problem for physicians and patients if they'd had to go backward.”
While some Republican governors, such as Rick Perry of Texas and Rick Scott of Florida, have declared that they won't comply with the law, there are provisions for that: if states do not set up their own health insurance exchange, the federal government will set one up for them. And although the Supreme Court declared that the federal government cannot withhold all Medicaid funding from states that don't expand their Medicaid programs to people below 133 percent of the poverty line, many policy experts believe that even the most philosophically opposed governors will ultimately comply, since the federal government pays for 100 percent of the Medicaid expansion in the short term and 90 percent in the long term.
“These aren't people who are making enough money to pay for their own care anyway, so the state has to take care of them one way or another,” said Gerard Anderson, PhD, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. (133 percent of the federal poverty level is a combined household income of just under $30,000 for a family of four.) “The governors will take the money and run.”
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But what does all this mean for neurology? For many patients with neurologic conditions, the end to lifetime caps and pre-existing condition exclusions will be (perhaps literal) lifesavers, said Dr. Jones. “The law also phases out the Medicare Part D ‘donut hole,’ which is good for our patients, because many of them are on Medicare and fall through that hole in some part of the year. Getting consistent coverage of their medications will be very beneficial to them. And permitting children to stay on their parents' insurance plans until they're 26 is very good for our pediatric neurology patients.” [The “donut hole,” as it is known informally, refers to the difference of the initial coverage limit and the catastrophic coverage threshold, as described in the Medicare Part D prescription drug program. After a Medicare beneficiary surpasses the prescription drug coverage limit, the Medicare beneficiary is financially responsible for the entire cost of prescription drugs until the expense reaches the catastrophic coverage threshold.]
AAN President Bruce Sigsbee, MD, also predicts better management of chronic conditions will improve quality of life and workplace productivity. “Migraine is a great example of such a condition,” he said. “Sporadic treatment for migraine, such as one gets in the ER, is far from optimal.”
But there are some down sides for neurologists in the ACA as well, most notably the fact that neurology remains excluded from the 10 percent primary care bonus payment on Medicare billings that the law authorizes for certain primary care specialties.
“We understand that this bonus won't be repealed, or replaced with one that recognizes neurology and other cognitive specialties,” said Mike Amery, the AAN legislative counsel. “So we need to focus on what's going to happen going forward. While neurologists don't want to be known as primary care providers, the reality is that they bill the same codes as primary care providers, have similar incomes, and face similar recruiting struggles. The only difference is that neurologists have more expensive and specialized training and often treat sicker, more complex patients.”
In May, Reps. Allyson Schwartz (D-PA) and Joseph Heck, D.O. (R-NV) introduced HR 5707, the Medicare Physician Payment Innovation Act. It's aimed at abolishing the Sustainable Growth Rate formula for physician payments that has caused so many headaches over the years as it mandates larger and larger pay cuts for physicians seeing Medicare patients, and Congress is forced to “patch” the losses — a process known as the “doc fix.”
This bill also provides for a differential payment system for primary care providers, but it improves on the ACA by eliminating the list of eligible specialties, and qualifying providers instead based solely on the amount of E&M codes they bill to the Centers for Medicare and Medicaid Services.
“Getting this legislation introduced is a huge success,” said Amery. “It's not about to be debated and signed into law any time soon, but for the first time, we have a bipartisan effort to improve the climate for primary care providers that includes neurology and other cognitive specialties if a substantial part of their practice is devoted to E&M.”
There's even a “down side” to getting more people insured: who's going to care for them? “There is overall a workforce shortage of physicians, particularly in primary care and non-procedural specialties such as neurology,” noted Dr. Sigsbee. “Given the shortage of primary care physicians, an additional burden will fall on neurologists for the neurologic chronic diseases such as epilepsy, MS, migraine, etc. Further, the law will lower the barriers to specialty consultation for the now covered population. In many areas of the country, particularly in rural areas, there will be an exacerbation of the already existing shortage.”
To ease these shortages, improved reimbursement models are essential. “People won't go into a medical specialty if it doesn't make sense from a financial standpoint,” Dr. Jones noted. “The ACA encourages innovative models of care, and hopefully one of the things that can be included in these models is collaborations, in which costs are covered more by systems than by individuals.”
It's been a slow, painful process to get even this far with health reform, but it had to happen, Dr. Jones said. “We had to start changing our system. It's tough to go through changes, but at least we're moving. It's a work in progress, imperfect and incomplete, but I think the AAN is doing a fabulous job of keeping neurology at the table and our members' and patients' needs at the forefront.”
But there's still a long way to go. Another wild card is the federal budget deficit, which cannot be fixed without reductions in health care spending. “In the past 3 years, 42 percent of federal expenditures represent deficit spending. Medicare and Medicaid are 25 percent of the Federal budget. Reductions in deficit spending, particularly if the reduction is through spending cuts alone, will include these federal programs to be successful,” Dr. Sigsbee warned.
POLICY WATCH — A COLLECTION
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