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Anesthesia management Archives - Page 17 of 20 - Xenon Health

Nov 11
0

The Implications of Bring Your Own Device (BYOD) in Healthcare

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Recent movements toward the democratization of data across information systems have fuelled a rapid uptake in the capabilities of mobile devices as a foremost means of access. The percolation of such influences through the foundations of organized healthcare has enhanced the spectrum of functions that medical professionals can employ in attending to patient needs. These include applications that extract and aggregate data from electronic medical records, harness neural networks on data sets to interpolate diagnoses on behalf of clinicians, produce timely drug references, or even interface with a sensor network to generate treatment compliance notifications and evaluate physical well-being. With a plethora of devices simultaneously connected to a distributed network, large quantities of data relating to potentially sensitive topics are exchanged every second across a complex web of stakeholders comprising doctors, caregivers, administrators, patients and their family members.

Connecting more devices and consumers to a network can confer the advantage of a broader array of patient cases from which to elucidate empirical insights. Furthermore, these would enable the current store of data to be employed in a growing set of circumstances, increasing the utility that each patient brings to the network. However, this same predicament could also undermine the viability of the mobile device network. A larger number of devices engaged with the network simply translates into a larger number of hazards from which unwanted intrusions into the network could occur, culminating in a spate of privacy breaches. Yet another cause for concern surrounds the interoperability of numerous network components that have developed around each other in an unmitigated fashion, imposing a huge strain on enforcing compatibility across different systems to facilitate information exchange, and in spreading finite computational power too thinly across a decentralized system.

Bring Your Own Device (BYOD) policies, therefore, offer a way for grappling with the security challenges associated with device usage within formalized healthcare information networks, such as those within hospitals, while helping to preserve the original mandate of these structures. This article highlights a number of key implications that BYOD may engender that are of immediate concern to the profession, alongside solutions that may be engineered to foster the productive development of the field.

BYOD could introduce multiple gaps in an otherwise closed network, possibly leading to data breaches. Paul McRae, director of healthcare solutions at AirWatch by VMware, discusses how healthcare systems are starting to involve mobile platforms as a workflow tool. Shrinking IT budgets often lead to compromises regarding non-performance related goals such as safety, leading to decisions not to purchase dedicated enterprise devices in favour of enrolling personal devices through WiFi networks. These trends were realized in part by the perception that data kept in a secure location accessible by mobile devices would diminish the need for data safeguards on the mobile device itself. However, the concentration of data at the nexus of a network with decentralized loci of entry control intensifies the risk of data theft, especially if personal devices in the network fail to encrypt data prior to transmission. As we discovered with the controversy that emerged when Anthem Inc was unable to adequately protect the social security numbers of 80 million customers, misplacing a single personal mobile device that lacks adequate identity verification mechanisms can result in the compromise of an unencrypted database. Experts postulate that having an integrated mobile device management security protocol that enforced a routine list of checks on all mobile devices accessing the network, while restricting access to devices with suitable decryption keys, could have limited the outflow of sensitive information considerably. However, this would be most feasible under an enterprise-level mobile device management plan managed by a single issuer, precluding the option of BYOD.

One of the major advantages to hospitals that advocate a BYOD environment is avoiding the costs of purchasing enterprise server-linked mobile devices for professional usage. Extending this line of logic further, we observe that it also combines professional and personal activities within a single point of contact, increasing the convenience and utility of an entity that has been gaining traction as an all-purpose device. The evolution of this trend could hypothetically diminish lag times in conveying professional alerts to healthcare professionals who would still be using their personal devices after work hours. However, research by Spyglass Consulting suggests the opposite. While 69% of hospitals interviewed reflect that medical professionals practice BYOD, it also indicates that typical hospital network infrastructures are far from well-equipped to handle this usage level. The report further contends that 25% of hospitals interviewed were dissatisfied with the quality and reliability of their wireless networks. Taken together, these results depict a dynamic in which usage convolution has dramatically spurred increments in network load in hospitals, resulting in trade-offs in terms of reduced bandwidth and network reliability in data service provision.

We would therefore require new methods of partitioning and approving network usage according to the priority of queries as a means of arbitrating between competing claims for resources in the interim, while focusing on extending the load bearing capacity of hospital network infrastructure to cope with heightening demand. As a start, traffic could be prioritized internally based on the application which issues data queries. At a hospital, for example, applications pulling critical information such as allergies from Electronic Health Records (EHR) would take precedence over costing applications, which would in turn be ranked ahead of social applications.

BYOD facilitates the movement of specialists such as anesthesiologists and radiologists between multiple healthcare facilities, which increases diversity of the contexts in which information is gathered and deployed. As specialists tend to be hired to fulfil highly niche roles within healthcare systems, it is also likely that they will experience the greatest degree of disintermediation when balancing between different facilities that run on different enterprise technologies. As such, they spearhead the BYOD revolution in owning the devices that are used to maintain connectivity, while leveraging the network assets of the facility for connectivity. A growing majority of end-user devices running on different operating systems echoes federal regulators’ call for a single network standard to establish a clear baseline for interoperability for encrypting all data on clinical wireless LANs. It is recommended that these standards also make provisions for flexibility in incorporating nascent forms of future technology, so as to enable unforeseen additions to the hospital’s wireless network at any point in time. To avoid dampening the incentives propping up the conversion to a BYOD paradigm, healthcare entities must invest resources in designing open-ended systems that are capable of commensurate levels of interoperability and security.

Nov 09
0

The Shift to Value-Based Payments in Anesthesia and Healthcare

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Healthcare providers and hospitals are in the midst of a significant change to the way they do business in the United States.  The traditional model of fee-for-service payments, under which health care providers are paid for each service rendered (lab test, office visit, procedures), is quickly being replaced with a new approach.  Under what is broadly termed the “value-based payment” model, payments to healthcare providers are tied to patient outcome, rather than simply on volume of services provided. While individual programs may vary in their details, value-based payments incentivize providers to deliver higher quality care and outcomes for their patients by tying payment to performance.

The ultimate goal of any value-based payment program is to reduce wasted health care dollars while at the same time improving patient health.  The U.S. has for some time, spent a greater percentage of its wealth on healthcare than any other industrialized nation; in 2012, nearly 17% of GDP (gross domestic product) in the US was spent on healthcare. Yet, despite spending significant resources on healthcare, the U.S. does not have the healthiest citizens. In one study comparing the U.S. to 10 other industrialized countries, the U.S. was ranked a dismal last place.  In fact, it is estimated that for 2015, the life expectancy in the U.S. will again be below the average for industrialized nations. Modifying the way healthcare is delivered and paid for is one approach being used to improve patient outcome and health in the U.S.

Both private and public health payers are embracing the idea of value driven reimbursement.  The Affordable Care Act (ACA) authorizes health insurance programs to utilize a value-based insurance design. Value-based insurance plans are designed to encourage insured beneficiaries to purchase lower-cost coverage and services, while encouraging providers to stop using wasteful services. More private payers are moving to value-based reimbursement models such as pay-for-performance (P4P) programs, under which providers are rewarded for meeting pre-established measures for quality and efficiency.

Other value-based reimbursement models include the use of Accountable Care Organizations (ACOs) and bundled payments, which are single payments that covers services delivered by two or more providers during an episode of care or during a specified time period. Such “episode of care” payment models are becoming increasingly common. These models require communication and cooperation across disciplines in order to provide quality care efficiently. Anesthesia providers are familiar with working with other disciplines and managing a spectrum of diseases in different settings. As a result, these providers can be particularly useful members of healthcare teams paid under an episode of care payment method and can help increase the value to both providers and patients.

In addition, both federal and state based payment systems are using value-based theories in constructing reimbursement schemes.  The Centers for Medicaid and Medicare Services (CMS) is moving quickly towards a value-based model. One method is known as the “Value-Based Payment Modified Program”. This program adjusts payments under the Medicare Physician Fee Schedule (MPFS) to a physician or group of physicians based on quality and cost of care provided. Adjustments can be positive, negative or neutral; thus, providers who provide high quality care at a lower cost can receive a positive payment adjustment while those providing low quality care at a high cost receive a negative adjustment. Determination of quality and cost is made through standardizing performance measures and creating benchmarks for comparison.

Physicians who receive payments under Medicare plans should be aware of another important value-based model of reimbursement.  Under the ACA, “eligible” healthcare providers (those who provide services under the Medicare Physician Fee Schedule) are incentivized to participate in a CMS qualified Physician Quality Reporting System (PQRS). This system encourages eligible providers to report information about their quality of care to Medicare in an effort to create databases of clinical data that can provide evidence-based information to inform best treatment practices and cost effectiveness. For providers of anesthesiology services, the National Anesthesia Clinical Outcomes Registry (NACOR) is the qualified PQRS. As with other physician reporting registries, NACOR provides a database of case data that can be used for purposes of quality improvement and benchmarking. Eligible providers of anesthesiology services who are covered under the reporting system include, Doctors of Medicine and Doctors of Osteopathy, but also Physician Assistants, Nurse Practitioners, Certified Nurse Anesthetists and Anesthesiologist Assistants.

What are the “quality measures” reported to NACOR or other types of quality reporting systems? The types of measures change annually and vary by specialty. Generally, quality measures will include areas such as patient safety, communication and care coordination, clinical care, and efficiency and cost reduction. Anesthesia core measures are based on the consensus recommendations of the Anesthesia Quality Initiative (AQI) and the Multicenter Periopoerative Outcomes Group (MPOG). For anesthesiology, measures are divided into interoperative, PACU Discharge, and Post-Op and measure various outcomes that could happen at each stage of patient care. There are many resources available to assist providers who are new to PQRS and who may be unclear about how to take quality measures or how to report data.

The move to value-based payments is intended to provide greater quality of care to patients. But what impact does this reporting system have on healthcare providers? While the reporting systems are considered “voluntary,” participation (and non-participation) does have a financial impact. Beginning in 2015, CMS will apply a negative payment adjustment to individual EPs and PQRS group practices that did not report on quality measures for services rendered in 2013.  All providers who meet reporting requirements for 2015 can avoid a negative payment adjustment in 2017. Providers failing to report in 2013 will receive a negative adjustment for 2015 and will be paid -1.5% less than the Medicare Physician Fee Schedule (MPFS) for that particular service. Starting in 2016, the adjustment will be -2.0%.  By penalizing providers who fail to participate, CMS seeks to encourage the reporting of quality information from eligible providers.

To thrive in the new healthcare paradigm, healthcare providers must become familiar with the change in payment models and understand how the latter works.  Participation in Quality Improvement initiatives is not only important for patient care but also for financial reimbursement in the current health care maelstrom.  Doing so will help keep healthcare practices financially sustainable and will also help them thrive in the competitive marketplace through measurable improvements in quality and cost of care.

Nov 02
0

Contracting with Healthcare Providers

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Once a medical practice has identified a healthcare provider to hire, it will usually want to sign a legal contract to formalize the relationship. This article briefly discusses some general considerations to keep in mind when negotiating such a contract. The most important advice is that the medical practice consult with a qualified lawyer before signing any contract. Legal language can seem deceptively straightforward but lead to counter-intuitive consequences; lay persons are therefore urged to seek expert counsel. Not doing so can lead to the contract being invalidated – or worse.

Parties to the contract

There will usually be two parties to the contract, the practice on the one hand and the provider (or some form of a representative of the provider) on the other hand. As a party to the contract, the medical practice should check that it has complied with legal and regulatory requirements. For example, a medical practice should verify that it is current with formalities, such as the filing of required reports with the local secretary of state and that it has complied with internal corporate requirements to be authorized to sign the agreement.

The counterpart to the practice in the contract will vary, depending on who found the provider. If a staffing agency presented the recruit to the practice, then the other party to the hiring contract will be the agency. If the medical practice identified the recruit on its own, that other party will be the provider herself (or an affiliated company of the provider).

Staffing agency placement vs. direct hire

Staffing agency placement

When a staffing agency introduces a healthcare provider to a practice, it will, broadly speaking, expect to be paid in one of two ways. Some agencies operate on a finder’s fee model and will ask for payment of a one-time, lump sum for pairing the provider with a practice. In industry terms, these payments are described as “permanent placement fees”, and can regularly exceed $10,000 for a single recruit. The other main compensation model is based on the amount of time spent by a provider in performing services. Here, the staffing agency will typically assign an hourly or daily rate to the recruit and invoice the practice for an amount equal to this rate multiplied by the time spent by the provider in performing services. With this model, practices should clarify early on whether related expenses such as provider malpractice insurance coverage or meal stipends are included in the rate. A medical practice should also resist cancellation clauses which impose unreasonable financial penalties if a practice must cancel scheduled coverage due to reasons beyond its control, such as patient cancellation or inclement weather.

Regardless of the compensation model, contract negotiation offers other opportunities to obtain favorable terms. For example, while staffing agencies typically expect settlement of invoices within 30 days or less, they will sometimes agree to extend this payment period to 45 – 60 days in exchange for the opportunity to develop a long-term relationship with the client practice.

Direct hire

Where it has found a provider on its own, a medical practice will enter into a contract directly with the provider. It can do so by hiring the provider either as an independent contractor or as an employee. Each option differs mainly around the control exerted over the healthcare provider and administrative burden placed on the medical practice, and must therefore be weighed carefully.

Independent contractor

Here, the practice hires the provider as an outside service contractor. Both the practice and the provider are independent entities contracting at arms’ length. Because the practice hires the provider as an independent contractor and not as an employee, it has less control over the performance of her duties and schedule. If the practice has an unexpected need for coverage, it may not be able to secure the services of the provider if that person has other obligations she prefers to attend to.

Despite this potential scheduling issue, many practices prefer to hire providers as independent contractors for administrative flexibility. Practices hiring an independent contractor do not have to comply with many labor requirements such as withholding payroll taxes or verifying employment eligibility. They also do not have to offer benefits. A practice choosing this route will execute with the provider (or an affiliated company of the provider) an independent contractor agreement, specifying issues such as the type, duration and frequency of services, compensation, protection of the practice’s confidential information, and malpractice insurance coverage.

Employee

Despite the higher administrative burden, many practices will hire providers as employees. Sometimes, a sought-after healthcare provider will insist on being hired as an employee to receive benefits. Also, a medical practice may prefer an employer-employee relationship to exert greater control over a provider’s performance of her duties and schedule.

To implement this option, the practice must follow applicable federal and state labor requirements. In some instances, this will mean executing an employment agreement with the provider. In other instances, signing such an agreement won’t be appropriate to preserve the practice’s ability to terminate employment at will. In hiring a healthcare provider as an employee, a provider will also have to address other material issues such as compensation and the protection of confidential information.

The preceding offers some general considerations which medical practices should keep in mind when contracting with healthcare providers. It is not intended to offer specific legal advice and readers are urged to consult with a qualified lawyer.

Oct 29
0

The Effect of Internet of Things on Healthcare Technology

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Introduction

The Internet of Things (IoT) describes a phenomenon[i] through which the operational aspects of the physical world become increasingly integrated with digital platforms, enabling information to move seamlessly toward the computational resources that are able to make sense of it. Its functionality derives from the interactions between three architectural layers: sensors tasked with data collection, communication networks between sensors that orchestrate data flow, and the analytical computational platforms that interpret these data and convey meaningful representations to users. Alongside the big data revolution, IoT is at the center of a substantial increase in the mobility and diversity of data which have helped usher in a new age of open information across a plethora of fields.

Unprecedented expansion in the capacity for data transfer at each of these levels has facilitated a big push in the healthcare sector to identify a more encompassing set of performance indicators, and attempt to record, track and analyze these exhaustively. By expanding the ambit of medical monitoring applications with the aid of portable devices, the Internet of Things has tremendous untapped promise in radically improving health outcomes, particularly with regard to the treatment of chronic diseases which expends an inordinate amount of human and economic resources.[ii] We thus examine some of the key enabling mechanisms which have contributed to the influence wielded by the Internet of Things on the developmental frontiers of healthcare technology.

Drivers

Big Data Infrastructure: The latent demand for healthcare insight has fuelled the development of data warehouses and algorithms which provide back-end support for processing information collected by the network of sensors in a big data ecosystem. This can be attributed to the increasing subscription to evidence based approaches that require individual data sets to be aggregated to constitute sufficiently sized populations, which can then be mined for statistically rigorous conclusions on treatment efficacy. This has redirected efforts downstream toward data collection and tracking through building up the network of data collection devices.

Widening Sensor Application: The deployment of cost efficient sensors at an increasing rate has permitted the IoT movement to gain traction in its progress toward a comprehensive network. Gartner forecasts there will be almost five billion connected devices by the end of this year and 25 billion in 2020[iii]. Sensors are now capable of being embedded in a wider spectrum of physical objects that span the healthcare sector and are connected to monitors real-time through the same internet protocol supporting the Internet. They assume a burgeoning array of functions including accelerometry, compass direction, positional tracking and environmental indicator logging, all of which generate usable information that can be interpreted by applications to form a more holistic picture of patient health status or mined for predictive insight.

Interoperability: With Internet of Things infrastructure unfolding in a bottom-up manner, policy actions to encourage interoperability across disparate information systems has helped unlock tremendous potential economic utility[iv] and broadened the set of interdisciplinary use cases of healthcare devices. As an increasing number of services gravitate toward benchmarks such as the Open Platform Communications (OPC) standard, healthcare applications relying on IoT become more adept at eliminating barriers to usage. The OPC standard was initially conceptualized in 1996 as a means of creating commonalities across various forms of industrial telecommunication, and continues to serve as a benchmark that various data transportation technologies rely upon to facilitate data access and interoperability. The convergence of these trends permits drawing on information from a patient’s demographic profile or consumption habits that might exist outside of his electronic medical records to make more accurate diagnoses and recommendations, and could also introduce one-stop-shop solutions that provide payment history or drive reimbursements alongside treatment recommendations. We learn that complex system design challenges depend on interoperability to acquire full employability across a variety of settings, from home health monitors to health informatics systems that mandate coordination over multiple levels.

Privacy/Security: As information of a sensitive nature is often contained within a healthcare information system, security rapidly emerges as an imperative. Safeguards restricting the flow of data in the spirit of HIPAA have sprung up in a prevalent manner, providing control in the form of virtual private networks demanding device authentication, secure booting, access management, firewalling and operational systems that receive periodic updates and patches to better acclimate to nascent cyberspace threats[v]. While imperfect, these set in motion a virtuous cycle that instills consumer confidence in committing sensitive financial and health-related information to these systems, which can be employed for greater benefit accruing to users, thereby coalescing into a precedent for continued investment into countermeasures that protect health information security.

Developmental Direction

The Internet of Things foray into healthcare is estimated to rise in total economic impact from $170B to $1.6T [vi]by the year 2025. Most of the benefits derived from this revolve around productivity enhancements, time savings, improved asset utilization, as well as complex real time monitoring and coordination. The successful manifestation of IoT can be observed in the use of multiple devices that have proliferated in the digital ecosystem that we have detailed in this article.

Complex Coordination: The interaction of infusion pumps for anesthetic drug delivery to a patient’s heart takes place at the foreground of a series of other exchanges between monitors, ventilators and healthcare professionals. A trained anesthesiologist works as a single nexus of control between numerous independently operating devices, and is required to oversee the delivery and keep track of patient status during the surgical procedure. This presents a challenge of combining information across various interfaces, preventing the false alarms that individual devices trigger from getting in the way of addressing actual healthcare threats, and most crucially, eliminating the risk of human error in causing further complications.

Systems such as the Integrated Clinical Environment (ICE)[vii]  consolidate supervisory, control and data logging capabilities within a connected, intelligent substrate, leveraging a Data Distribution System that can parse through real time data streams quickly to discern which of these genuinely require human intervention. ICE could coordinate drug combination infusions to the patient with inputs from the electronical medical records and calibrate quantities through the device directly, thus reducing the avenues through which human error could undermine care quality. By centralizing a locus of control that is able to obtain an encompassing perspective of all indicators, ICE avoids misguidedly reallocating resources in response to false alarms that might result from low oximeter readings, instead undertaking corrective action only when both oxygen and carbon dioxide levels signal a lowered respiratory rate.

Facilitating Appropriate Intervention: Treatment procedures that are self-administered frequently report reduced effectiveness relative to regimes that fall under the supervision of nurse practitioners, partly due to the heightened susceptibility to family member interference, unexpected patient conditions, or a lack of discipline to follow through with tedious, repetitive procedures[viii]. Ginger.io provides a mobile application that allows diabetic patients to submit to tracking by their mobile phones, and receive strategic healthcare interventions while going about a regime that is largely enforced on a personal level. With the aid of mobile phones that have been retrofitted with the requisite sensors, the location, contact details and movement of these individuals are tracked directly. These are then interfaced with public health research insights developed by the NIH in comparison with other sources of behavioral health information. The insights extracted from the real time data streams arriving from the application can suggest patterns of behavior that might be consistent with illness or patient comorbidity. For instance, failure to move about in accordance with daily routines could indicate a lack of well-being, prompting healthcare professionals to take a closer look at other indicators or engage the patient directly.

Situational Awareness: The large amount of sensors deployed across all geographic locales and collecting various different types of data provide a fertile ground for collaboration with healthcare specific applications[ix]. These provide the concerned entities with a grasp of all the possible variables that might affect their well-being, which can prove critical in the case of ailments that are extremely sensitive to external environmental variations. Asthmapolis offers a GPS enabled tracker that measures inhaler usage by asthmatics, taken against a backdrop of externally oriented asthma catalysts. Usage levels are collated by a central database and inspected against environmental conditions that contribute to inhaler usage, such as particulate concentration in air, presence of pollen or volcanic fog. When such information is subsumed under a spatial map, asthmatics are able to acquire a transcendent awareness on areas to avoid in order to mitigate their symptoms.

Implications

Experts concur that there persists immense untapped potential for the application of Internet of Things in a healthcare setting. To ease into an environment where the merits of such integration outweigh the embryonic hazards, various stakeholders need to systematically address some key concerns that have surfaced through recent application[x]. Consumers, for instance, will have to strike an equitable balance between granting agencies permission to access private data and discerning which sets of information are of material significance in a field characterized by informational overload. Technology suppliers have to wrestle with the challenges of making sensors and network solutions increasingly affordable, such that the benefits can accrue to even the most underprivileged in society. Public policy regulators, have to actively set precedent in promoting market conditions for the drivers that have made IoT an abiding pillar in healthcare technology.

[i] http://www.wired.com/insights/2014/11/the-internet-of-things-bigger/

[ii] http://www.forbes.com/sites/tjmccue/2015/04/22/117-billion-market-for-internet-of-things-in-healthcare-by-2020/

[iii] http://www.gartner.com/newsroom/id/2905717

[iv] http://www.mckinsey.com/insights/business_technology/the_internet_of_things_the_value_of_digitizing_the_physical_world

[v] http://dupress.com/articles/internet-of-things-iot-in-medical-devices-industry/

[vi] https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/PDFs/The_big_data_revolution_in_healthcare.ashx

[vii] http://electronicdesign.com/communications/internet-things-can-save-50000-lives-year

[viii] http://www.forbes.com/sites/85broads/2014/03/26/4-ways-the-internet-of-things-is-transforming-healthcare/

[ix] http://www.mckinsey.com/insights/high_tech_telecoms_internet/the_internet_of_things

[x] http://www.philips.com/a-w/innovationmatters/blog/how-the-internet-of-things-is-revolutionizing-healthcare.html

Oct 26
4

Impact of The Affordable Care Act on Physician Reimbursements

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The Patient Protection and Affordable Care Act (PPCA or commonly called ACA), passed by the Obama Administration in 2010, creates several key changes within the American health care system that addresses health care affordability and availability in order to include national coverage. The Affordable Care Act includes “guaranteed issue” and “community rating” requirements, and individual mandates. These reforms compel insurers to provide coverage to any person regardless of their current and pre-disposing medical health conditions, and prohibit insurers from charging patients different coverage premiums for similar conditions.  The individual mandate, which requires individuals to have health insurance coverage or else incur an IRS fee, ensures that more individuals, both young and old, are obliged to obtain some form of coverage. States may set up health insurance exchanges under the Affordable Care Act allowing Americans within their state insurance exchange to obtain ideal coverage plans from competing private health care providers. Americans in states that have chosen not to elect a state exchange may sign up under the federal exchange to acquire coverage. While the new legislation most immediately and obviously impacts patients, the change it creates in the overall American health care system affects another key player in health care- the physicians.

As a result of the passing of the Affordable Care Act, physicians can expect to see a boom in the number of patients they care for. Especially with the recent Supreme Court ruling in King v. Burwell allowing for tax credits on both state and federal exchanges, more individuals have access to coverage and health services. The exchanges remove a major obstacle in acquiring insurance coverage for patients and allow for more patients to seek out primary care physicians. Additionally, a new Affordable Care Act revision, effective January 1, 2014, required insurers to cover ten specific services, referred to as “essential health benefits”, and sixty-three different preventive services. These newly-covered services include maternity care, mental health services, medications, rehabilitation services, chronic disease management, blood pressure and mammography screenings, a variety of immunizations, childhood behavioral and autism screenings, and access to contraception [1].As a result of such widespread coverage, physicians do not have to collect out-of-pocket payments directly from patients and will instead receive them as reimbursements from health plans.  Due to the ACA’s individual mandate and expansion of covered services, physicians can expect to see a rise in their reimbursements due to a greater influx of patients, especially those of the younger generation, seeking them out for their services.

Along with an increase in the number of reimbursements, physicians also saw a rise in reimbursement rates from the ACA during 2013 and 2014. To entice physicians to accept patients who have insurance under Obamacare’s new exchanges, legislators added a provision to raise reimbursement rates. With the ACA promoting primary care as one of its main goals, primary care physicians’ Medicaid reimbursement rates in 2013 and 2014 were raised to match Medicare rates [5]. Furthermore, primary care doctors and general surgeons received a 10% percent bonus for opening or continuing to practice in medically underserved communities. Furthermore, Medicare primary care physicians received a 10% bonus for primary services from 2011 through 2015 [4]. For reference, Medicare, the federal health coverage provided for seniors, offers physicians a reimbursement rate of approximately 80% of what private health insurance pays. Medicaid, which provides coverage for low-socioeconomic individuals who qualify, reimburses physicians a much lower rate of about 56% [3]. The Affordable Care Act focused on providing greater availability to primary care. Physicians who supported the ACA saw a large increase in their reimbursement rates, leading to an overall higher revenue.

However, this “two-year bribe” to enlist the support of physicians for the new Medicaid insurance plans had expired on January 1, 2015 [3]. As a result, the Medicaid reimbursement rates for physicians have decreased in 2015. An Urban Institute report has estimated a 42.8% reduction in Medicaid reimbursement rates for physicians as a result of the readjustments to pre-2013. The magnitude of the reduction depends on whether or not states have decided to extend the Medicaid primary fee bump using their own state funds.  Due to ongoing budgetary concerns, many states were unable to use their own funds to extend the fee increase policy [3]. This has resulted in a variation of reimbursement rates across states. Alabama, Colorado, Iowa, Maryland, Mississippi, and New Mexico have elected to continue paying primary care services at the Medicare level. Conversely, Alaska, Connecticut, Delaware, Hawaii, Maine, Michigan, Nebraska, Nevada, and South Carolina are paying Medicaid fees at higher rates, but are not necessarily at the same level of Medicare rates. At least 24 states have chosen to revert back to their lower pre-2013 rates [2]. Ultimately, the foreseeable problem from the fee cuts is that doctors will be reluctant to accept patients under Medicaid due to the lower rates, potentially resulting in accessibility problems for patients.

With the differences in high and low reimbursement rates between states, there is an opportunity here for legislators to evaluate the effect of increased primary care rates. By comparing the data from states that have continued to increase rates versus data from states that have reverted to their pre-2013 rates, we can learn how changes in physician reimbursement affect accessibility to patient health care. Looking forward, legislators can utilize the examination of the different rates to provide information on the effects of the proposed fee bump policy, ultimately using previous precedents to determine whether or not the fee bump should be continued, standardized, or eliminated across all states. We need to consider and address the role policy plays in physician’s decision to support the ACA, while keeping in mind the Affordable Care Act’s ultimate goals to provide easier access and more availability to primary care services.

 

Sources:

[1] Bendix, Jeffrey. “Affordable Care Act Affects Reimbursements.” Medical Economics: Health Law & Policy. Medical Economics. 25 July 2012. Web. 22 Oct. 2015.

[2] “An Update on the Medicaid Primary Care Payment Increase.” MacPac: Publications. MacPac. Mar. 2015. Web. 18 Oct. 2015.

[3] Matthews, Marrill. “Doctors Face A Huge Medicare And Medicaid Pay Cut In 2015.” Forbes: Healthcare, Fiscal, and Tax. Forbes. 5 Jan. 2015. Web. 22 Oct. 2015.

[4] “Obamacare and Doctors.” Obamacare Facts. Obamacare Facts. n.d. Web. 21 Oct. 2015

[5] Page, Leigh. “8 Ways That the ACA Is Affecting Doctors’ Incomes.” Recruiting Physicians Today 21.5 (2013). New England Journal of Medicine. Web. 18 Oct. 2015.

[6] Zuckerman, Stephen., Skopec, Laura., McCormack, Kristen. “Reversing the Medicaid Fee Bump: How Much Could Medicaid Physician Fee for Primary Care Fall in 2015?” Urban Institute Research. Urban Institute. 10 Dec. 2014. Web. 20 Oct. 2015.