Drug coverage. Loan repayment. Care coordination. Doctor reimbursement. Beyond the looming questions of access, affordability, and capacity, rheumatologists say the ACA could impact them and their patients in a variety of ways both big and small.
For older patients, the law will close the Medicare Part D “doughnut hole,” or gap in prescription drug coverage for those with high co-pays, by 2020. “A lot of what impacts us is considerations around some of the higher-priced medications, such as infusion drugs,” says Timothy Laing, MD, a rheumatologist and the associate chair for clinical programs for the department of internal medicine at the University of Michigan in Ann Arbor. Whether expensive chemotherapeutic and biologic agents are covered under Medicare Part B or Part D and whether they appear on Medicare’s self-administered drug exclusion (SAD) list, for example, may have a strong bearing on the extent of patient co-pays.
For rheumatologists, the law may have less of an impact on reimbursements. Dr. Laing notes that Medicare’s reimbursement rates, for example, are governed far more by the Sustainable Growth Rate (SGR) than by any provision within the ACA. Ultimately, however, all of Medicare’s funding has to come from the federal government, meaning that the law’s financial impact may weigh more heavily on future reimbursement decisions. “If the net result is accelerated spending on Medicare, then that will put more pressure on entitlement reform,” he says. “If it lives up to its promise and the cost curve gets bent or keeps bending appropriately—because it is bending at the moment—then there may not be quite so much pressure on reimbursement.”
Other provisions, such as the law’s pediatric subspecialty loan repayment program, could help alleviate the shortage of pediatric rheumatologists by easing doctors’ debt burden after medical school. “We’re very hopeful that it will help,” Dr. Laing says. “The concern has long been that people will be less likely to choose a lower-paying subspecialty if they have to pay off large loans.” Although authorized, however, the loan repayment program still exists only on paper because it has not yet been approved for any funding. “It’s like buying a car and finding out, ‘Oh, you wanted wheels?’ ” Dr. Laing says. Medical associations will continue lobbying political leaders on Capitol Hill to appropriate the necessary funds, he adds.
Although the Centers for Medicare and Medicaid Services (CMS) is changing how it conducts its audits, potentially increasing the burden on small practices with complex billing but small staffs, Dr. Laing says many rheumatologists are more concerned about the switch to a complicated new coding system for diagnoses. The International Classification of Diseases version 10, which will be mandated in October 2014, he says, could hit small practices hard because of the necessary training and computer upgrades. “There’s a lot of concern that when this system is turned on that physicians’ payments will be affected because their claims will be rejected because they don’t have them coded properly,” Dr. Laing says.
Salahuddin Kazi, MD, associate professor of medicine in the division of rheumatic diseases at the University of Texas Southwestern Medical Center in Dallas, says the ACA is also increasing the emphasis on coordination among providers. Beyond the concept of a patient-centered medical home, where the primary-care physician is empowered to create a team, providers are also embracing the concept of a patient-centered medical neighborhood, which includes much more coordination with specialists.
Ultimately, Dr. Kazi says, optimizing workflow, reducing waste, aAnd standardizing care will help rheumatologists handle the additional patients. “We’re going to have to lean on our support personnel much more,” he says. “We really need to leverage all of the other workers within the practice to work at the top of their license and to contribute more.”