Part 2/3: ACA needs a reality check
This is part 2/3 of My prescription for better health care for ALL Americans.
With the new president-elect nominated by the American electoral college, there are increasing worries about repealing the Affordable Care Act (ACA). Is it possible to repeal such significant legislation of our time? Will millions of Americans lose their insurance coverage?
Since its inception in 2010, an estimated 20 million of the estimated 47 million uninsured Americans gained health insurance coverage with surveys pointing towards many satisfied customers not only with their plan but also their chosen doctors. Studies, as cited by the Common Wealth Fund, also suggest an improvement in quality of care as a result of ACA implementation. In the last 6 years, there has been increasing interest in multi-payer initiatives to promote quality primary care by reimbursing physicians a set fee per member of their practice (sounds like the government likes direct care but won't admit it).
All this sounds great, right? So what is all the fuss about?
Well lets look at what this "coverage" means for the average ACA enrollee:
Think about this: When a person gets admitted, the hospital staff runs them through a myriad of exams and tests quickly to maximize their revenue (initial evaluation is highest paid with decreasing reimbursement for follow up visits), and then discharge them to the clinic setting where the wait times are long and the patient has little time with the doctor. The social workers and case managers will be the first to tell you there are several moments during a hospital discharge, we can predict someone will likely come back (called LACE score). To add to all this chaos, add the fact that the insurance companies will deny medications that at discharge might be needed or imaging that is needed for follow up. Hey, but I have coverage, right? Delay in care with prior authorization and denial of medications is what only the American who experiences this in some way truly understands.
Health care is a $3 trillion industry. Each change in policy means millions of dollars worth of changes in staffing and organizational structure for hospitals. Like any other business, these costs will need to be recovered in some way. Thus, the rising hospital bills, avoiding certain payers completely, and entertaining providing services in a cash basis without involving insurance; it's so much cheaper!
Health insurance adds about 5 staff members for each physician with denial of claims about 15-20%. Accounts receivables increase as the facilities await payment while continuing to pay for billing services to resubmit and submit new claims. This is the single largest cost and waste in our health system. From direct costs of paper, printing, software and hardware, billing services, to indirect costs of time wasted, prior authorizations, insurance denials and requests for more forms, less patients seen due to paperwork, and burn out. This is the foundation for the need to see 20-30 patients daily to capture a reasonable revenue stream to keep the business running. More on this in the final blog post.
Enter direct care.
The American Academy of Family Physicians (AAFP) proudly supports direct primary care and holds the single largest conference in Kansas City, MO every year. This single event has grown from a few 100 to over thousands of attendees, including physicians, medical students, medical residents, technology vendors, and others who are eager to partner with direct care practices across the nation.
Their tremendous support stems from the growing national shortage of primary care physicians, increasing prescription medication costs, poor access to care, and unaffordable medical care despite insurance coverage.
The American College of Physicians (ACP) has also written a white paper on practices contracting with their patients instead of insurance companies. This paper has increased the conversation differentiating direct primary care from concierge care. A social media storm was lead by yours truly. Sorry ACP, but I cannot tolerate poor research prior to writing a paper.
Here is the reality:
How would this new health system look like? I discuss this in my final blog post for this 3 part series.
"He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all."