Fallout from 2010 law continues for doctors, hospitals, insurers 

A patient experiences a medical emergency and is admitted to the local hospital. One of the first questions he’s asked, besides his name and date of birth is . . . are you insured? If so, what is your health insurance plan and policy number?

So begins the time- and money-intensive dance between illness, treating that illness and paying for the privilege of treatment. It’s the bedrock of the American healthcare system – and continues to be despite reforms introduced by the Affordable Care Act of 2010.

“I think what we’re seeing is it’s a period of adjustment for everyone,” said Craig Becker, president of the Tennessee Hospital Association.

From a physician’s perspective, the situation has only grown murkier, and more costly, with time as “wave after wave of regulations come down,” Becker said. This is especially true as requirements continue multiplying the costs associated with patient care and the positive outcomes demanded by the law, many observers indicate. 

“Some of the regulations are crazy,” Becker said, “but some are worthwhile.”

At the heart of the issue are insurance companies, which Becker acknowledged continue to be a dominant player in healthcare delivery: how long a patient is treated, what services can (and cannot) be rendered and what is (or is not) considered acceptable along the care continuum.  

During a recent budget hearing, Julie Mix McPeak, commissioner of the Tennessee Department of Commerce and Insurance, had this to say: “The Affordable Care Act has had a profound impact, and continues to impact, insurance providers in the state of Tennessee. The 2010 statute has established parameters that control providers’ operations, from the underwriting process right on through the benefit packages offered to consumers.”

As reported previously in Memphis Medical News, this and other aspects of the law have led to a wave of consolidations between physicians’ groups and hospital systems, allowing them to insulate themselves, at least to an extent. It also has helped them “gain more clout” when negotiating contracts with payers, Becker said.  

However, the transition has been less than smooth, according to McPeak’s recent remarks.

“Unfortunately, ACA implementation has also complicated the business of insurance for our carrier community,” she said in a statement. “The stepped rollout of the legislation, coupled with reliance on Department of Health and Human Services discretion, has often led to providers searching for answers and last-minute revisions to business operations.”   

 This was particularly evident when physicians received notice from Blue Cross Blue Shield of Tennessee (BCBS-TN) in November 2013 that the insurance company would

be amending its contract so doctors would receive a 48 percent reduction in the reimbursement cost, set by 2013 Medicare payments standards, for all services deemed “in-office physician lab services.”

The amendment went into effect on Jan. 1, 2014. At the time of the notice, doctors were given until Dec. 20, 2013, to decide whether they would accept the amendment. Ultimately, they did; it was either that or opt out altogether. And the situation is not unique.

Becker said it is something that, ultimately, could result in some kind of single payer, state-run system such as Medicare for all. In that case, healthcare would be financed by a public- or quasi-public entity, but care delivery would remain in private hands, according to Physicians for a National Health Program. 

“We don’t know what it’s going to morph into,” Becker said. “I don’t know if this was intended (by the law) or (might be) a consequence of it.”

Unless or until such a thing occurs, larger physicians’ and hospital groups are here to stay, he said, and smaller, more rural providers aren’t likely to survive. “I think we’re going to see a lot more of that.”

As it is, about 60 percent of physicians are being hired under some type of agreement with hospital systems, what Becker calls “an enormous jump” that likely will not slow.

Meanwhile, insurance premiums have increased for patients in Tennessee, while Medicaid coverage has not been expanded – yet.

“At least from a hospital standpoint, access to care might be getting worse,” Becker said.

However, the care itself might just have improved.

“Frankly, I think care’s gotten better because of what we’ve been able to do with safety and quality of care,” he said, meaning more attention for patients and fewer details missed as primary care doctors, specialists and hospital systems are forced to coordinate more closely.

That, he said, is where the ACA’s intent – and the reality of it, admittedly a “mixed bag” – are most marked. “In the end, it’s all about the patient,” he said.