The Affordable Care Act: 10 essentials you need to know

National Report-Predicting just how the Affordable Care Act will impact urologists is like forecasting a volatile stock market’s impact on investors. Even experts don’t quite agree on what will happen to U.S. urologists as a result of Obamacare.

What urologists can do is anticipate important changes from the ACA and how those might affect the number of patients they treat, what they get paid, how they practice, and how what they do is recorded by the government and viewed by the public.

Urologists who are health policy experts say these are 10 things practicing urologists should know.

1. Brace for more patients, or maybe not.

Many predict that an influx of new patients will be among the early changes.

Dr. Penson“The ACA expands Medicaid by increasing the eligibility level to 133% of the federal poverty level. This means that many people who currently have no insurance will now have Medicaid coverage,” said David F. Penson, MD, MPH, the AUA’s health policy chair and professor of urologic surgery and medicine, Vanderbilt University, Nashville, TN. “In addition, the ACA mandates that Americans have health insurance and provides subsidies to aid people in need to buy insurance. Both of these elements of the ACA will result in an upsurge of new patients coming to see urologists.”

Kevin R. Loughlin, MD, senior surgeon at Brigham and Women’s Hospital and professor of surgery (urology), Harvard Medical School, Boston, says physicians in Massachusetts got a preview of the ACA with Romneycare. Romneycare, he says, resulted in more patients seeking care and more pressure on physician offices to maintain access to patients.

“No matter how complete the implementation of the ACA, there are going to be more patients. I think it is likely that more urologists are either going to start using physician extenders if they haven’t already, or if they are using physician extenders, they will expand or depend on them even more, simply to take care of the volume of patients,” Dr. Loughlin said.

On the other hand, some say the anticipated patient influx might not become a reality.

“Number one: They’re not signing up. Number two: More people are losing their insurance, perhaps, than are signing up. And number three: The ones that do sign up and have large deductibles-many of them won’t be able to afford… or they’ll be very cautious about going to a physician because they’re paying out of pocket for most of it,” said Jason Shelnutt, CEO of Georgia Urology, a 41-physician group in Atlanta.

2. Current patient coverage will change.

Mr. RutherfordEmployers of all sizes might terminate employee coverage or change it if their current plans don’t meet ACA standards, according to Rick Rutherford, director of practice management at the AUA.

“This may increase the amount of administrative work to be done by your staff to gather sufficient information to make these changes in your billing data,” Rutherford said.

Next: Urologists might have little or negotiating power

3. ACA fees aren’t universal, and urologists might have little or no negotiating power.

Urologists in the Medicare program know the fee schedule, upfront. That’s not the case with ACA patients. ACA exchanges operate more like commercial plans, where fees vary, according to Rutherford.

But while urologists and other specialists have the right to negotiate with commercial policies, Rutherford says it is unclear whether doctors will have the right to negotiate with the Affordable Care policies through the exchanges.

4. Consider collecting your fees upfront.

Many of the exchange policies being sold have large deductibles of $3,000 to $5,000 or more.

“A lot of these lower-rung metal plans are really just catastrophic insurance. A lot of patients who are forced into the system are buying lower-level, or entry-level, plans. They carry very high co-pays and very high deductibles, which means the patient that comes to your office is going to bear a large part of the [financial] burden,” said Jeffrey Kaufman, MD, an AUA board member and part of a 55-urologist group in the Greater Los Angeles area. “If urologists don’t collect their co-pays, they may not collect.”

Shelnutt says practices that are not prepared to deal with getting payment on the front end should expect larger and extended accounts receivable and collection processes.

“We have for many years tried to handle patient responsibilities at the point of service. And we have designed systems within our practice management software that allow us, based on our specific contracts, to determine a patient’s responsibility before they leave the office and collect. You don’t get 100% of that, but you do get a fairly sizable percentage,” Shelnutt said.

Collecting money upfront is particularly important, given the next thing urologists should know…

5. If ACA patients don’t pay their premiums, you might not know it and your reimbursement could be in jeopardy.

The way the exchange policies are required to work is that patients have 30 days of coverage once they enroll. They then have another 60 days before they are officially kicked out if they don’t pay their premiums, Rutherford says.

The problem for the urologist, Dr. Kaufman says, is if the physician sees the patient during the first 30 days during which a patient is delinquent, the insurance company will stand behind its guaranteed payment.

“But if a doctor sees a patient and causes a charge for days 31 through 90, the claim will be ‘pending.’ At the end of that time, if the patient hasn’t become current with the premium, the insurance will notify the doctor that the patient wasn’t actually covered and the patient owes,” Dr. Kaufman said.

Insurers are not obligated to post whether patients are current.

Dr. Kaufman“If doctors don’t check eligibility and know that the patient is staying current, they could get burned,” Dr. Kaufman said. “There are some practices that recognize this and they’ve said that they are going to insist on a cash down payment. And if the insurance pays, the doctor will refund the money. You can imagine the ethical, moral, and legal challenges that poses.”

Dr. Kaufman, who represents the American Association of Clinical Urologists as a delegate for urology to the American Medical Association House of Delegates, says he and colleagues have taken a first step to address the problem by passing a proposal that the AMA encourage a law requiring insurance companies to post eligibility and notify a doctor if a patient is delinquent. If the AMA were successful in getting legislation passed regarding the grace period, Dr. Kaufman says, it would lead to two outcomes: real-time verification of delinquency of premium payments and, if an insurance company indicated the patient had coverage, such notice would guarantee payment.

Next: Urologists might be reimbursed more often for what used to be charity care.

6. Urologists might be reimbursed more often for what used to be charity care.

A possible silver lining for some urology practices is that many of the patients urologists see in the emergency department and, subsequently, in the office will now have a source of payment. In the past, the charges were often written off as bad debt, Rutherford says.

7. Today’s emphasis is on bundled fee payments.

The ACA is focused on value-based purchasing and proposes a number of novel reimbursement models to encourage consolidation and shared risk in health care, according to Dr. Penson.

The new terms, including accountable care organizations (ACOs), medical homes, and episodes of care, describe bundled fee models.

“You won’t see urologists creating ACOs or medical homes. ACOs and medical homes are going to be primarily created by primary care physicians. And because urology is responsible for a small portion of the health care dollar, we’re going to be on the tail end. We’re not going to be in a strong negotiation position,” Dr. Kaufman said.

The solution, according to Dr. Kaufman, is for urologists to join together because there is power in numbers.

This could put pressure on urologists in solo or small group practices to form larger groups or become employed, according to Dr. Penson.

8. With the greater emphasis on transparency and quality reporting comes headaches for urologists.

While the greater emphasis on transparency and quality reporting should be a positive aspect of the ACA for doctors and patients alike, it doesn’t look at what’s meaningful in urology, Dr. Kaufman says.

There are multiple ramifications as health care shifts from fee for service to value-based performance reimbursement.

“One is physicians have to participate. Most urologists are involved in the Physician Quality Reporting system, or PQRS, using electronic health records. Second, you have to demonstrate quality. Third, you have to control costs,” Dr. Kaufman said. “PQRS reporting requirements expanded from a minimum three in 2013 to a minimum nine beginning 2014. So, whether you do it based on claims or registries or as part of a group, you’re going to have to report your quality.”

The problem, Dr. Kaufman says, is this: As of now, Medicare grades urologists’ quality on what he says are inappropriate parameters.

“I’ve conferenced with Medicare on this, on behalf of the AUA,” Dr. Kaufman said. “Medicare has me defined by how many spirometry tests I do for lung patients and how many eye exams I do for diabetic patients, as well as how many beta-blockers I give to MI patients. You can’t measure my quality as if I’m primary care.”

The AUA is working to define meaningful quality parameters and will propose Medicare uses those, he says. In the meantime, urologists be aware.

Defining quality parameters is only half the battle, according to Dr. Kaufman. Another challenge in this area is appropriately measuring cost. In Dr. Kaufman’s experience, Medicare is looking at the wrong things to properly define the costs a urologist generates.

“There could be a patient that I touched. I diagnosed him. He leaves my office and gets a very expensive set of tests at UCLA and a very expensive surgery at USC goes to Loma Linda for extensive radiation and goes to UC-Irvine for very expensive chemotherapy. All these dollars are generated and the responsibility may flow back to me, even though I didn’t order the treatments,” Dr. Kaufman said. “When I look at my report, I got really good grades. But when I looked at it, it had nothing to do with what I’m doing.”

In the shift to value-based payment, Medicare should make sure that what it is measuring is meaningful, relevant, specialty specific, and that the costs really are the costs, he says.

For quality reporting, Medicare is using patient satisfaction surveys, which look at such things as the quality of magazines in the waiting room and the amount of time to get an appointment. Quality reporting is also based on social media reports, which he says can be wildly inaccurate.

Unfortunately, this is the information the Centers for Medicare & Medicaid Services will use in its public reporting, he says.

Next: Tighter cost controls on the horizon

9. Tighter cost controls are on the horizon

Dr. Penson predicts urologists will be among the physicians seeing tighter cost controls after the initial rush of more insured patients. The Independent Payment Advisory Board (IPAB) is at the root of his concern.

“I don’t think that IPAB will cut urologists’ reimbursement preferentially. I worry that they will cut all provider reimbursement, regardless of specialty,” Dr. Penson said. “The way the legislation is written, IPAB can only cut doctor reimbursement during the first few years of its existence. If IPAB has to make cuts to reduce spending (and there are strict criteria in the ACA regarding when they have to take action and how much they have to cut), they can’t cut hospital payment, payments to pharmaceutical companies, etc. In the first years of IPAB, the only group they can cut are the doctors.”

The government is heavily emphasizing shifting resources toward primary care at the cost of specialists, Dr. Kaufman says.

“The sustainable growth rate debate is favoring primary care over specialists. The bundled fee… is favoring primary care over specialists. The relative value unit system is being reshuffled in the same way,” he said.

10. Be ready… for just about anything.

Dr. LoughlinOne thing that appears certain about the ACA is the uncertainty about the specifics of its implementation, according to Dr. Loughlin.

“We’ve already seen there have been several delays in implementing parts of it, and we also know that the 2014 election is likely to be very volatile. There are still budgetary issues that are going to be in play and then, on top of that, I think… one has to appreciate the heterogeneity of urologic practice in this country,” he said.

The health care system’s dramatic evolution will likely continue, according to Dr. Loughlin.

“I think what urologists are going to have to do is… to be flexible and versatile, but also to really get involved. They should get involved not only for their own edification to have the knowledge to assess what’s happening, but also to impact the environment in their local practice area-to make sure it’s the best thing for their patients and the best environment to deliver urologic care,” Dr. Loughlin said.UT

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