Because the year 2015 promises to be one filled with important healthcare challenges, Memphis Medical News took the opportunity to talk with Keith Anderson, MD, a Memphis cardiologist and chairman of Board of Trustees of the 8,000-member Tennessee Medical Association, about a number of issues, including the fallout from the Affordable Care Act and its impact on doctors, hospitals, insurers.

Here are his responses to questions posed by the newspaper’s Lindsay Jones.

Memphis Medical News (MMN) – When the Affordable Care Act was passed, it was touted as being a vehicle to help average Americans obtain health insurance at better rates, even if they might have pre-existing conditions. Although coverage has expanded for many, it appears the health insurance industry has become even more influential in the ways services are delivered and billed (and how expensive premiums really are). What is right and wrong in the overall process as it exists now?

Anderson – It’s safe to say that physicians and other healthcare providers have strong personal opinions about the Affordable Care Act. It’s a little more difficult at this point to say on a wholesale level what is right versus what is wrong with the current process. We have seen more people accessing health insurance coverage through the exchange, and that’s a good thing.

In terms of payment and delivery models, the biggest change continues to be the transition from the traditional fee-for-service model to new value-based reimbursement models. Payers and providers are both trying to figure out how to operate in a system that includes rewards and penalties based on efficiency and quality measures. The episodes of care in the State of Tennessee Health Care Innovation Initiative is one example.

MMN – Recently, BlueCross BlueShield unilaterally changed its contract terms so doctors would be reimbursed much less for certain tests and services. Most practices complied because they really had no other choice, even though this happened after they already had set their budgets. This is but one example among many of some marked strong-arming during contract talks. So, just how much power or leverage do insurance carriers have when it comes to applying the Affordable Care Act's mandates? Why does this situation seem to be accelerating unchecked? Are some companies more known for this kind of tactic than others?

Anderson – This example is not really a byproduct of the ACA. It’s commonplace among health insurance companies, and has been for some time. Doctors contract to be in health plans’ networks to get predictable patient flow, but have little to no negotiating power, especially independent physicians and smaller groups. The insurance industry’s “take it or leave it” approach to network contracts and unreasonable reimbursement modifications in mid-contract is the reason TMA brought the Payer Accountability legislation before the General Assembly in 2014. We simply want health plans to honor the agreed upon contract provisions for the full contract term. This will be among our top legislative priorities again in 2015 and, if we are successful, will be the first law of its kind in the United States.

What it is attributable to the ACA is a narrowing of options or insurance providers for patients and employers. There are fewer plans, which in turn gives the industry more power to set the rules for providers – both in and out of their networks. Patient steerage will be an issue to watch in the coming year.

MMN – ACA is/was supposed to be about rewarding physicians not for the number of tests or inpatient procedures they perform, but for favorable outcomes among patients. How is this possible, however, when it appears insurance companies can set care parameters by withholding funds from providers? In other words, it seems that in the end, patients are getting the short end of the stick because of how hamstrung their healthcare providers are.

Anderson – It’s important to remember that the ACA is just an umbrella regulatory mechanism at the federal level. There are lots of different ways health plans, health systems and providers are trying to achieve the apex of quality, safety and efficiency. Some are proving to be more successful than others. All parties – payers, providers and even the patient – need to have skin in the game for this type of payment model to really be successful, and to truly get more value out of each episode of care.

We are in the very early stages of implementation of only a few episodes in Tennessee. What we already know is that there has to be better transparency of information and clinical data. There is also a longer view concern that this strategy for managing care will face a diminishing return and effectiveness in a short period of time.

MMN – What do you see as being the biggest issues in Tennessee right now, related to healthcare and insurance providers?

Anderson – Undoubtedly the biggest issue weighing on healthcare in Tennessee is the crushing weight of overregulation and mandates to perform work that has little or no value to patients.

MMN – What are some of the factors that determine whether a healthcare entity (physician practice, hospital-owned practice, etc.) can withstand or overcome the limitations imposed on it, mainly by insurance companies?

Anderson – Time is the biggest factor. Physicians have seen a dramatic increase in the administrative side of medicine. Some larger groups or employed physicians may have personnel resources to support administrative burdens, but nearly all physicians have to deal with technology, federal and state regulations, payer requirements and a host of other demands that don’t have anything to do with patient care. Most physicians will agree that they want more face time with patients but have an increasingly difficult time finding it. We cannot deliver the highest quality care without preserving the doctor-patient relationship.

MMN – How do the spectrum of needs and problems in healthcare differ between urban and rural areas (for example, metro Memphis and rural West Tennessee)?

Anderson – Access to healthcare is among the most obvious and ongoing issues. People living in rural West Tennessee counties may have to commute to Jackson or Memphis get the care they need, especially for complex chronic conditions. By contrast, residents in Shelby County or other metropolitan areas typically have their choice of doctor, hospital, etc., and are probably not inconvenienced when referred to a specialist.

One trend that may exacerbate access issues is the merging and consolidation of practices with hospitals and health systems. When a practice becomes part of a larger group, they may not participate in the same insurance programs or networks, and patients may be affected.

MMN – Aside from the negative aspects of this continuing issue, what are some positives happening in terms of the insurance industry and care providers?

Anderson – We are encouraged by the efforts being produced by our work between various medical professional organizations and groups. For example, TMA is working with the Tennessee Academy of Physician Assistants to advocate for more integrated, patient-centered healthcare delivery teams. The quality and value-driven healthcare climate calls for a more team-based approach. If we in Tennessee can work more closely together in a coordinated, integrated manner, then we will give patients better access to care without compromising quality, so they have the best possible patient experience, and we will lower costs in the process. We have also seen a dramatic increase in our workings with the hospital industry related to payment bundles and episodes of care. We have always worked closely together, but new pay models are changing the intensity of our working relationships to align our vision and mutual performance for delivering patient care together.

MMN – What do you foresee in the future for this issue? Will it be necessary to reform healthcare reform, or is the landscape going to be made up of mainly hospital-system-owned practices and clinics to help sustain the shortfalls in reimbursements? A lot of that has been happening already ... but where, do you think, will it end? What will it ultimately look like?

Anderson – Wish we could say. Healthcare is traditionally slow to reveal and adapt to trends when compared to other sectors of our economy. I think it will be some time before we truly see whether the changes we are implementing now are the best solutions for the long term. I don’t believe we can ever consider ourselves and done with healthcare reform. Medicine has to continually adapt to meet the needs of our patients, now and in the future. It is our nature to be cautious and challenging to new ideas and we will always start our evaluations with the question of good medicine and the relative value to the patient . . . the safety of our patients . . .

We let science and evidence be the best indicator of what works and what does not our opinion of our healthcare system.