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:

1. Average deductible range $5,000 to $6,000 
2. From 2015 to 2016 premiums on average have increased 10-16%
3. Many had to change physicians and many physicians stopped accepting many insurances, including Medicare and Medicaid
4. Large number of health systems across the country stopped taking Medicaid and Bronze plans
5. Longer wait times to see a primary care physician as the volume increased and the supply decreased

Most Americans do not care about the impact ACA has on the business of medicine as most people care more about how much they have to pay and what the ACA means to them. But what people fail to realize is that all Americans are INDIRECTLY affected by the increased regulations and policies that came into effect as a result of the ACA. Readmission penalties, hospital acquired infection penalties, Medicare reimbursement cuts, and other policies incentivize refusal of care of patients at high risk for readmission, triaging these patients to other facilities, and delayed discharges because of the fear of readmissions. These regulations mean less time to see patients, refer them to specialty care quickly, additional testing given the lack of time in the exam room, and hospitals are placing more burden on the clinics to continue care after discharge to decrease their length of stay. 

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. ​

Summary

Here is the reality: 

1. Many Americans cannot afford paying for several plans under the ACA.
2. If they are able to get coverage, the out of pocket expenses, high deductibles, long wait times, and short visits lead to reactive behavior rather than proactive. This leads to rising costs of medical care personally and nationally.
3. Short visits or poor access to care lands people in the ER with higher expenses. 
4. Cost of medications conflict with household budgets constantly leading to poor compliance of medications and follow up care.
5. Many health care providers do not take Medicaid, Medicare, and various private insurances in order to stay in business. This illustrates the common mantra "health insurance does not equal health care." 
6. Premiums and deductibles are outpacing earnings and inflation. Offering quality coverage is clearly becoming impossible. So many plans will provide "coverage" to an American, but the details of the plan will illustrate that it barely pays for basic medical services. 

Solution 

1. ​Privatize all outpatient services that are office-based. This would include primary care, all specialty follow up care, small office procedures which can include endoscopy, bronchoscopy, ENT procedures, some urological procedures, and other services. No insurance billing in these facilities. 
2. Outpatient laboratory, imaging, and medications should also be where services are rendered without involving insurance companies. The cost of these services are significantly lower on a cash only basis than they are with hospitalizations. 
3. Insurance companies should be involved only with inpatient services. This is important: Just because you are admitted to a hospital does not automatically qualify as inpatient stay. There is a status call observation status where insurance companies will say that the admission is like a outpatient visit on steroids where you don't need full admission, but not safe for you to go home. Under observation status, the patient is responsible for the entire bill. The American public has no idea the amount of arguing insurance companies do behind the curtain and threaten to deny services.

So as much as that plastic card may seem all warm and cozy in your wallet, realize that their interest is not paying for anything and will threaten or deny care for you the minute it is possible. It is your doctors, case managers, and social workers who are fighting to continue to provide you the care you need. 

How would this new health system look like? I discuss this in my final blog post for this 3 part series.

Cheers!
​Dr. Ahmed