In a much-anticipated decision, the U.S. Supreme Court validated most provisions of the Patient Protection and Affordable Care Act (ACA) as constitutional on June 28, 2012. But what is the immediate day-to-day impact of the landmark ruling upholding the law and its expansion of healthcare coverage to tens of millions of patients?
Not much, say experts. The value of the ACA, according to two leading rheumatologists, is in how it will shape the healthcare system for providers and patients.
First, the Act will increase access to rheumatologists for patients and, over time, eliminate the Medicare Part D prescription drug coverage donut hole. Stanley B. Cohen, MD, a rheumatologist with Rheumatology Associates in Dallas and a past president of the ACR, has noted that under the current system, patients who spend over $2,700 enter a coverage gap until their out-of-pocket costs exceed $6,150. This gap will slowly close until it is eliminated in 2020.1
Second, the ACA includes the Pediatric Subspecialty Loan Repayment Program, which, if funded by Congress, will pay back up to $105,000 of loans for physicians who agree to provide three year of pediatric service in underserved areas. While the program was authorized by the ACA, it has yet to be appropriated any funding.
“The first wave of impact is that the Affordable Care Act is constitutional, and that offers the possibility of more access and more coverage for patients to have rheumatologic care and rheumatologic treatments,” says Joseph Flood, MD, president of Musculoskeletal Medical Specialists, Inc. in Columbus, Ohio, and secretary of the ACR.
Dr. Flood believes the loan repayment provision could help spur more budding physicians to choose pediatric rheumatology as a subspecialty. As a faculty member at The Ohio State University College of Medicine and Public Health in Columbus, Ohio, he says the need is great for the next generation of pediatric and adult rheumatologists.
“We’re hoping that Washington, in addition to providing access to care for our patients, also makes sure that physicians are appropriately reimbursed for their services, and for rheumatologists, in particular, being appropriately reimbursed for their services has a big impact to patient care,” Dr. Flood adds. “Not just Medicare patients, but if rheumatologists are unfairly compensated, then the young students I try to get excited about rheumatology every day in my office probably won’t choose rheumatology as a specialty. And that has enormous impacts on access to care.”
Tim Laing, MD, chair of the ACR Government Affairs Committee, says one of the potential pitfalls of the ACA ruling is that some physicians will interpret it to mean that Congress and the federal government has mostly dealt with the issue of medical funding.
But, he says, rheumatologists need to continue to talk about the Sustainable Growth Rate (SGR) formula before Congress. At issue is the future of rheumatologists’ Medicare payments—including the federal Medicare Payment Advisory Commission’s (MedPAC) recommendation from last year to scrap the formula, reduce payments for specialist services by 5.9% for each of three years, and then freeze them for seven more years—and the 27.4% SGR cut that has been repeatedly delayed by extensions. The current deadline for the 27.4% payment cut to take place is the end of this year.
“Everyone is faced with flat or declining reimbursements,” Dr. Laing says, adding that physicians need to continue to lobby federal officials for a permanent solution to the SGR formula. “Congress needs to be aware of the situation, needs to understand the pressure that’s there because it ultimately affects access to Medicare.”
Dr. Laing has hoped for a long-term fix to the formula that balances patient access and physician reimbursement, but is now fearful talk of the ACA’s approval will lead to less of a focus on solving the problem and the potential for more temporary fixes.
“Medicine deals with uncertainly all the time,” he adds. “You just go forward with what you have and you hope for the best.”
Dr. Flood put it this way: “I feel often like the coyote in the Road Runner cartoon series, where’s he jumped off the cliff, something’s going to happen, but he has no idea what. I think a lot of rheumatologists feel that way. We’re not sure how we’re going to fit in to accountable care organizations or other new care delivery systems.”
Richard Quinn is a freelance writer based in New Jersey.
