14 questions (and answers) about health reform and you
The Patient Protection and Affordable Care Act has ramifications for ObGyns and their patients. ACOG’s director of government affairs answers our questions about the law.
IN THIS ARTICLE
DiVenere: Congress included two provisions to target “young immortals,” young adults who don’t think they need health insurance because they’re young and healthy and never need to see a doctor. Many young adults are not offered employer-based health insurance, and many see no advantage in buying coverage that they don’t expect to use. But we all know that someone pays when any uninsured person falls sick or has an accident that necessitates medical care.
Beginning this year, adult children as old as 26 years can go onto their parents’ health insurance plan. In addition, catastrophic plans will soon be available to individuals younger than 30 who want to purchase a higher deductible plan through their state exchange or on the individual and small group markets. These catastrophic plans are not required to include the essential benefits package, including maternity care. Nevertheless, both of these provisions should be helpful to ObGyn practices.
12. Will the mandate for employers to provide health insurance affect many ObGyns?
DiVenere: The employer mandate takes effect in 2014, when employers with more than 50 employees, at least one of whom receives a premium tax credit, are required to offer health insurance coverage to employees or be assessed a range of fees. Employers that have 50 or fewer employees are exempt from this requirement.
In 2007, 75% of ObGyn practices had fewer than 42 full-time employees, with an average number of full-time employees, including physicians, of 34.4. So this mandate should not apply to the average ObGyn practice.
A range of small business tax credits for employers that contribute at least 50% of the cost of coverage for their employees will also be available, with credits phasing out as the size of the firm and the average employee wage increase.
13. Who will benefit from the Medicare geographic payment adjustments?
DiVenere: The increased Medicare geographic practice cost index (GPCI) payments and new Frontier payments won’t affect many ObGyns nationally, but they are likely to affect most ObGyns in the related rural locations.
The law reestablishes the national average floor on Medicare’s GPCI for physician work. In 2010 and 2011, Medicare makes a separate adjustment for the practice expense portion of physician payments that will benefit physicians in rural and low-cost areas.
Beginning in 2011, a third adjustment will increase the practice expense GPCI for physicians in frontier states. A frontier state is one in which at least half of its counties have populations smaller than six people per square mile. Frontier states are expected to be Montana, North Dakota, South Dakota, Utah, and Wyoming.
Physicians in 51 localities in 42 states, Puerto Rico, and the Virgin Islands will benefit from the two practice expense adjustments.
ObGyns should also know about two other payment changes:
- The HHS Secretary will create and apply to Medicare provider payments a value-based modifier that will result in higher Medicare payments for high-quality, low-cost physicians and lower payments for high-cost, low-quality physicians. The modifier is to be based on a composite quality score and a composite cost score determined by measures selected by the HHS Secretary and endorsed by a consensus organization. This change begins with 2015 Medicare payments and applies only to physicians in 2015. In 2017, it will also apply to other health professionals.
- Effective immediately, the HHS Secretary has the authority to increase or decrease Medicare relative values, and payments for services, with special attention focused on:
- – services that have high growth rates
- – services that have seen substantial changes in the practice expense or work components
- – services for which new technology has reduced costs
- – instances in which multiple codes are frequently billed for a single service
- – codes that have not been reviewed since implementation of the resource-based relative value scale (RBRVS).
ObGyns who participate in Medicare will start receiving individual physician resource use reports in 2012. These reports will compare per capita utilization of physicians (or physician groups) with the utilization rate of physicians who see similar patients. Reports are required to be risk-adjusted and standardized to take into account local health-care costs.
14. Do you expect the law’s requirements for “administrative simplification” to reduce overhead and increase efficiency?
DiVenere: Don’t we all hope so.
The bill contains several requirements such as:
- establishment of a standardized claim form
- streamlining of claims processing
- improvement of interoperability to allow for more electronic information sharing. These changes will not be implemented until 2013 at the earliest.
Today, about 34% of all ObGyn practices use electronic health records. The systemwide benefits of health information technology (HIT) can be many. Insurers can save by reducing unnecessary tests. Patients can benefit from better coordination of care and fewer medical errors. But these advantages don’t necessarily translate into savings or revenue for physician practices.
