Patient Protection and Affordable Care Act: Find What’s Missing. Keep What Works. Fix What’s Broken.
A. Find What’s Missing in the PPACA
Sustainable Growth Rate: Flawed Physician Payment Formula
The Sustainable Growth Rate (SGR) is a flawed funding formula the Centers for Medicare & Medicaid Services uses to pay physicians for the care they provide to Medicare patients.For the past decade, physicians have faced double-digit pay cuts because of the flawed SGR. Only emergency congressional intervention stopped cuts each year. The uncertainty surrounding the Medicare program, especially in this time of change, makes it extremely difficult for physicians to plan for the future. As a result, fewer physicians are taking new Medicare patients. The new health care law did not address this problem.
TMA Ask: Repeal the broken SGR. Enact a rational Medicare physician payment system that works and is backed by a fair, stable funding formula. Fix the broken Medicare payment system before giving additional increases to any other providers.
Medical Liability Reform
Texas has gained more than 21,000 new physicians to take care of Texas patients since 2003. Of these, around 5,000 can be attributed to Texas’ medical liability reforms. Many of these new physicians practice high-risk specialties such as emergency medicine, neurosurgery, pediatric intensive care, and pediatric infectious disease. Texas patients now can get more timely and convenient care when needed. Twenty-one rural Texas counties have added at least one obstetrician since the passage of Texas’ medical liability reform, including 12 counties that previously had none. The emergency care provisions have saved lives by helping ensure Texas patients have access to critical and timely care. The 2003 liability reforms have worked. They’ve lived up to their promise. Sick and injured Texans now have more physicians who are more willing and able to give them the medical care they need.
The rest of the nation will benefit from Texas-style reforms
TMA Ask: New medical liability reforms must measure up to the “Texas-size” reforms. New national medical liability reforms must NOT modify or change reforms now in Texas law.
Antitrust Relief for Physicians
The Federal Trade Commission prohibits a physician’s ability to clinically integrate as imagined by the new health law. The new health law asks physicians to collaborate in ways government has discouraged through antitrust laws. For physicians to clinically integrate so they provide efficient care as imagined by the PPACA, a broad, bright-line rule needs to be established so physicians can work together without fear of government discipline.
TMA Ask: Congress needs to provide antitrust relief for physicians so that they can organize to provide cost-effective care and be protected from unscrupulous corporations putting profits before patients.
As baby boomers come of Medicare age, increased flexibility in Medicare will be necessary to ensure patients have access to a physician. One way to accomplish this is to allow Medicare patients to see any physician of their choice. Physicians should be allowed to enter into direct contracts with Medicare patients, even when they opt out of the Medicare.
TMA Ask: Pass the Medicare Patient Empowerment Act. Give physicians the ability to directly contract for any and all Medicare services.
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B. Keep What Works in the PPACA
Insurance for People With Preexisting Conditions
From July to October 2009, TMA conducted 16 town hall-style meetings (aka House Call meetings) on health reform across Texas with more than 3,000 patients and physicians participating. At every meeting, both patients and physicians called on Texas legislators and Congress to prohibit health insurance companies from excluding coverage for patients with preexisting conditions. Patients need access to health care coverage, especially when they suffer from an ongoing medical condition. The PPACA now helps patients who have a preexisting condition obtain and maintain coverage when they are sick.
TMA Ask: Maintain the PPACA provision prohibiting insurance companies from excluding coverage to patients with preexisting conditions.
Prohibition on Rescissions
Patients should not lose their health insurance, especially when they need it most, because of an honest mistake when filling out health insurance paperwork or applications. Prior to the PPACA, health insurers could rescind a patient’s insurance policy if they discovered an alleged misrepresentation in the patient’s initial application for insurance, even an honest mistake or omission.
When coverage is rescinded by an insurer based on a misrepresentation on the application, all coverage is rescinded, leaving the patient responsible for paying for all of his or her health care services past and present. Health insurance applications are confusing, and sometimes people make honest mistakes in completing the forms.
TMA Ask: Insurers should not be allowed to cancel a patient’s health coverage over technicalities in completing forms.
Medical Loss Ratios
Health insurer profits are expressed as part of the industry’s term “medical loss ratio.” The medical loss ratio is the percentage of premium dollars spent on payments to physicians, hospitals, and other health care providers for health care services rendered. The premium dollars left include health plan salaries and overhead, as well as profits. Simply stated, insurers can maximize their profits by spending less on a patient’s health care.
Employers and employees are spending more money on health insurance coverage each year. Yet they have no idea if their hard-earned premium dollars are going toward health care or elsewhere. Prior to the adoption of the PPACA, there was not a single definition of a medical loss ratio. This made it impossible for employers and patients to compare health plans. TMA believes a consistent reporting formula for medical loss ratio works. Now employers and patients can compare health plans with others when shopping for insurance.
TMA Ask: Maintain the PPACA provision requiring health insurers to use a consistent reporting formula for medical loss ratio.
Consumer Label for Insurance and Plain Language Explanations
Purchasing health insurance coverage today is increasingly complex. Health insurance companies offer a wide range of plans with different benefits, exclusions, and costs. It is nearly impossible to decipher a health insurer’s sales literature, then make a direct, product-to-product comparison.
Employers and patients need accurate, current, and honest information on copayments and deductibles to make decisions in today’s health care market. The real need for this information is not when patients are sick or injured but rather when Texas businesses and their employees are shopping for health insurance coverage.
Standardized and reliable nutritional labeling has made it much easier for consumers to make better food choices. Consumers can examine 20 different boxes of cereal and easily compare the product benefits, such as number of calories and percentage of fat, sodium, sugar, or protein. TMA believes the same standardized system could aid employers and consumers when shopping for health insurance. The PPACA contains an insurance label requirement, and TMA agrees that plain-language information (like the label) will aid our patients.
TMA Ask: Maintain the PPACA provision requiring health insurance labeling in plain language so patients can better understand their insurance coverage.
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C. Fix What’s Broken in the PPACA
Independent Payment Advisory Board
The law creates a 15-member Independent Payment Advisory Board (IPAB) that has the authority to control Medicare spending, starting in 2015. IPAB can make recommendations that lead to decreases in Medicare spending ONLY through lower payment rates to physicians. IPAB recommendations would become law automatically unless Congress passes a law to reach the same budgetary savings.
The issue of Medicare spending is too important to be left in the hands of an unaccountable board with decisions based solely on cost.
TMA Ask: Repeal the Independent Payment Advisory Board. Keep Congress accountable for the Medicare system. If decisions are made to limit funding for health care services, priorities will have to be set. It should not be left, however, to an unelected and unaccountable IPAB.
Workforce/Graduate Medical Education
Texas medical schools are doing their part to expand medical student enrollments. However, graduate medical education (GME) programs are not growing in the same fashion. As a result, many of our newest physicians end up moving to other states for their residency training. GME is a necessary part of a physician’s preparation for medical practice. Physicians who complete both medical school and GME in Texas are three times more likely to remain in the state to practice.
Texas’ medical schools and teaching hospitals have limited funding available to expand GME. The shortage of GME slots guarantees some medical students will be forced to leave the state upon graduation. Those leaving likely will not return to Texas. They will take with them more than $200,000 of state investment in their medical school education. The current model for funding GME in the United States has not changed in more than 15 years. This significantly hurts the ability of states like Texas to offer GME programs to medical students.
TMA Ask: Maintain GME funding through Medicare and consider adjustments for future support based on population growth.
Overbearing "Fraud and Abuse" Enforcement
Healthcare Fraud Criminal Statute
Texas physicians recognize the need to rid the health care system of fraud. We want to work hand in hand with Congress to ensure our health care system operates effectively and efficiently. The PPACA includes provisions that increase funding and the government’s authority to combat fraud and abuse. Language was changed in the Healthcare Fraud Criminal Statute that might have unforeseen consequences. The law removed the government’s burden to show that an accused had “actual knowledge of the law or specific intent to commit fraud.” It added this new language: ‘‘(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.” As a result, many physicians may be charged as criminals for honest mistakes. Honest mistakes or errors should not result in a government crackdown.
TMA Ask: Revisit and/or remove language relating to the Healthcare Fraud Criminal Statue
There also are additional written requirements regarding MRIs, CTs, and PET scans. Physicians now must inform patients in writing at the time of the referral that they may obtain services elsewhere and provide a list of others who provide such services in the area. Physicians already are required to seek preauthorization for most imaging services. They should not also be required to compile and maintain a list of other imaging providers. If the federal government mandates a list, the government should provide it. More paper, more processes, but where is the health care?
TMA Ask: Revisit the imaging referral provision and remove the arduous paperwork requirement, so physicians can spend more time taking care of patients versus pushing paper.
Antidiscrimination Provisions for Health Plans
The PPACA includes a provision stating health plans may not discriminate against any health care providers — acting within their state scope-of-practice laws — who want to participate in the plan.
TMA Ask: Ensure this provision is not misinterpreted to permit providers who have not been trained as physicians to misrepresent themselves as possessing the education, knowledge and training of physicians.
Restrictions on Hospital Ownership
Throughout the health care debate, the Mayo Clinic, Cleveland Clinics, and Texas‘ Scott & White Hospitals were held up as the gold standard of how to deliver efficient and high-quality care. All these institutions have one thing in common — they are physician-owned and physician-led. In the future, these types of institutions are banned. A provision in the PPACA (under the guise of “fraud and abuse”) actually prevents physicians from establishing hospitals that participate in Medicare. The PPACA makes future hospital ownership illegal for physicians who go to medical school, obtain a license to practice medicine, care for Medicare patients, and then want to refer their Medicare patients to a hospital in which they may have ownership. If a physician had already owned a hospital, the PPACA severely limits how that hospital can expand and operate moving forward.
TMA Ask: Repeal legislation that limits physician ownership of hospitals. Promote responsible ownership of all health care facilities, whether owned by a physician, hospital, or other provider.
Accountable Care Organizations: Fairness
The accountable care organization (ACO) is a new concept in the PPACA. It asks for physicians to invest in a new model of health care delivery that increases efficiencies and delivers the right care at the right time. However, the incentives in the program are left to the whim of federal administrators. A participating ACO can’t challenge many government decisions about the performance of an ACO, including:
- Whether the ACO is eligible to share in any savings it creates,
- The amount of shared savings to be paid to the ACO,
- Which patients the government assigns to the ACO,
- What measurements the government plans to use to determine the quality of care the ACO provides,
- The government’s assessment of the quality of care the ACO provides to patients, and
- A determination to terminate the ACO from the program.
TMA Ask: ACO rules must be fair and equitable, and must recognize physician leadership on issues related to patient care, quality assurance, and clinical integration. Physicians should not be viewed simply as another source of labor.
Funding for Health Information Technology
The Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the American Recovery and Reinvestment Act, provided funding and incentives for physicians to adopt electronic health record technology. As a result, many physician practices have made significant investments in these technologies. They are working to integrate these systems into their practices and meet the “meaningful use” criteria established to receive the financial incentives. However, just as these investments are being made, Congress is considering bills that would repeal or significantly reduce its support for HIT.
TMA Ask: Protect the HITECH Act from repeal. Continue with the current incentive program to help physicians acquire electronic health record systems. This will improve health care in America in so many ways.
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