American College of Physicians: Internal Medicine — Doctors for Adults ®

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Now begin the nuts and bolts of health care reform

From the June ACP Internist, copyright © 2010 by the American College of Physicians

By Robert B. Doherty

Health care reform is now the law of the land, even though the political arguments continue. This year changes affecting private insurers, Medicaid and Medicare will take effect, and many more will roll out in the next four years.

Recognizing this, the American College of Physicians has started an educational campaign for members on the nuts and bolts of the law. The goal is to provide ACP members with objective, clear and practical information on specific elements of the law, prioritized by the direct impact on internists and their patients and how soon the changes become effective.

ACP is first providing information on changes in payments to internists or in their patients’ insurance benefits that occur within the next six to 12 months. Materials will then be updated on a rolling basis as more becomes known about plans for implementation. Information will be provided to members through ACP advocacy’s Web site, the ACP Advocate e-newsletter, the ACP Advocate blog, other ACP electronic communications, and this column.

Immediate changes

Some changes affecting private insurance will begin this year:

  • A temporary national high-risk pool will provide health coverage to individuals with pre-existing medical conditions;
  • Insurers will be required to offer dependent coverage for young adults up to the age of 26;
  • Individual and group health plans will be prohibited from placing lifetime limits or rescinding coverage; and
  • Insurers issuing new policies will be required to provide coverage, at no out-of-pocket cost to patients, for preventive services that get an A or B rating from the U.S. Preventive Services Task Force.

Also this year, the federal government will provide tax credits of up to 35% of premiums to businesses that employ 25 or fewer employees and have average annual wages of less than $50,000 per employee. (Owners’ salaries are excluded from the annual wage calculation.)

A national workforce commission will soon be established to provide comprehensive, unbiased information about how to align federal health care workforce resources with national needs. The commission is required to examine the barriers of entering and remaining in primary care careers, including payments.

Medicare changes

Medicare patients also will begin to see changes in their covered benefits, starting this year. If they reach the Medicare Part D “doughnut hole,” they will receive a $250 rebate to offset a portion of their costs.

Even bigger Medicare changes are slated for 2011:

  • Seniors who end up in the “doughnut hole” will get a 50% discount on their brand-name prescriptions.
  • Medicare will begin paying for seniors’ preventive services with no cost-sharing. Seniors also will be covered for a comprehensive health risk assessment and personal treatment plan.
  • Beginning on Jan. 1, 2011, general internists, family physicians, pediatricians and geriatricians will be eligible to receive a 10% Medicare payment bonus on their office, nursing home, home and custodial care visits. To qualify, 60% of their total Medicare allowable charges must be for such services.
Looking ahead

A bit farther down the road, starting in 2012, Medicare and Medicaid will begin pilot tests of different ways to pay physicians.

Physicians who join with hospitals to achieve better outcomes, such as by reducing preventable hospital admissions, will be allowed to share the Medicare savings with them and the federal government.

Medicaid (starting in 2012) and Medicare (starting in 2013) will test paying physicians a “bundled payment” (all-inclusive fee) for treating a particular set of medical conditions. The federal government also will fund several initiatives to accelerate testing and adoption of the patient-centered medical home by Medicare, Medicaid and private insurers.

Beginning in 2013 and continuing through 2014, primary care physicians will get increases in Medicaid payments for visits and for immunizations, so that they are paid no less than what Medicare pays for the same services.

Over the next four years, the federal government will also offer grants to medical schools and residency programs and provide more scholarships to increase the numbers of primary care physicians.

By 2014, states will have to set up purchasing pools, called health exchanges, to allow small businesses and people who do not have access to employer-paid coverage to get group purchasing discounts on qualified health plans.

At that time, all health plans, whether offered through an exchange or not, will be required to cover basic benefits, including providing coverage of preventive services with no cost sharing. Insurance market rules will be in place to prohibit insurers from denying, cancelling, failing to renew, or charging higher rates to people with medical conditions. Individuals and families with incomes up to 400% of the federal poverty level will be eligible for subsidies to help them buy coverage through the exchanges. Medicaid will also begin covering everyone with incomes up to 133% of the poverty level.

As soon as possible, ACP will provide detailed information on how these and other changes will be implemented.

The Patient Protection and Affordable Care Act is highly unlikely to be repealed as long as President Obama is in the White House, although some revisions will probably be made. No matter where they stand on the legislation itself, internists will need information from a trusted source, the American College of Physicians, on the nuts and bolts of how it affects them and their patients.

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